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HARVARD UNIVERSITY 



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LIBRARY 

OF THE 

Museum of Comparative Zoology 



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I'v ir ,-7 



REPORTS 

OF THE 

COMMISSION 

APPOINTED BY 

THE ADMIRALTY, THE WAR OFFICE, AND 
THE CIVIL GOVERNMENT OF MALTA, 

FOR THE INVESTIGATION OF 

MEDITERRANEAN FEVER, 

UNDER THE SUPERVISION OF AN 

ADVISORY COMMITTEE 

OF 

THE ROYAL SOCIETY^ 



PART VI. 



LONDON: 
HARBISON AND SONS, ST. MARTIN'S LANE, 

PBHTTIBS IN OBDnriBY TO HI8 MAJESTY. 



April, 1907. 

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CONTENTS. 



Page 
I. Beport upon the Baoteriologioal and Experimental Investigations during the 
Summer of 1906. By J. W. H. Eybb, M.D., P.R.S. Edin., Bacteriologist 
to G-uj's Hospital and Lecturer on Bacteriology in the G-uy's Medical 
School ; Major J. 0. MoNaught, M.D., B.A.M.C. ; Captain J. C. 
Kbknbdy, M.B., E.A.M.C. ; and T. Zammit, M.D., G-ovemment 
Analyst, Malta, and Professor of Chemistry, Malta University 3 



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I. REPORT UPON THE BACTERIOLOGICAL AND EXPERI- 
MENTAL INVESTIGATIONS DURING THE SUMl^IER OF 
1906. 

By J. W. H. Eyre, M.D., F.KS. Edin., Bacteriologist to Guy's 
Hospital and Lecturer on Bacteriology in the Guy's Medical 
School ; Major J. G. McNaught, M.D., R.A.M.C. ; Captain 
J. C. Kennedy, M.B., R.A.M.C.; and T. Zammit, M.D., 
Government Analyst, Malta, and Professor of Chemistry, Malta 
University. 

SYNOPSIS OF CONTENTS. 

Page 
Preliimnary Notes on Methods 4 

I. — The Goat s^ a Factor in the Dissemination of Malta Fever. 

1. The distribution of miich goats naturallj infected with Micro- 

coccus melitensU 7 

2. The agglutination test as applied to the miloh goat 14 

3. The numerical relationship of M. melitensU to the milk of infected 

goats 19 

4. The presence of ilf. me/t7e»«i> in milk products 25 

5. The susceptibility of the goat to, and path of infection by, 

M. melitenns ! 28 

6. The localisation of M. melUeHsU in the infected goat 36 

7. The transmission of M. melitensU antibodies to the descendants 

of infected goats 41 

8. The treatment of infected milch goats with Jf. melitensis vaccine 42 

II.— If. m^/tVeNm Infection bj Experimental Feeding with Infected Goats* 
Milk. 

1. General considerations 44 

2. Feeding experiments with naturally infected milk artificially 

reinforced 48 

8. Feeding experiments with naturally infected milk alone 57 

4. Olinioal features of food infection ( Jf. melitensis) in the monkey.. 66 
6. The action of hydrochloric acid and of artificial gastric juice on 

J£. melitensis 68 

IIL — M, melitensis infection following the ingestion of infective milk in 

man 70 

B^um^ of the outbreak of Mediterranean Fever on board the ss. 
" Joshua Nicholson." 

1. History of the goats 70 

2. Incidence of Mediterranean Fever among those \\-ho 

partook of the milk 71 

3. The results 72 

<13984) h 2 

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4 Dr. Eyre, Major McNaught, Capt. Kennedy, and Dr. Zammit 

Paob 

lY. — The Bdle of the Mosquito and other Blood-sucking Inseots in the 
Dissemination of M. melitensts. 

1. Species of mosquitoes occurring in Malta 7S 

2. Supply of mosquitoes, and notes on their habits in captiyitj 77 

8. Duration of life of Jf. melitentis in the body of the mosquito ... 80 

4. Experiments with J corf omyia ZammtYu 82 

Duration of life of Jf. melUensit in Acartomjia 88 

Virulence of M. melitentis after passage through Aoartomjia 85 

Aoartomyia as the infectiye agent 85 

5. Experiments with Stegomyia ftuciaia 91 

Duration of life of Jf. mslitenns in Stegomjia 91 

Stegomjia as the infectiye agent 92 

6. Experiments with other species of mosquitoes 94 

7. 'Biimg 9Lie%, 8tomoxy9 calcitrant 9& 

Duration of life of Jf. melitentit in Stomoxjs 96* 

Stomoxjs as the infectiye agent 97 

8. Fleasandbugs 99* 

y. — Naturally acquired infection (M. melitentis) in various animals 101 

y I. — M. melitentis infection by means of Personal Contact 107* 

VII. — Prophylactic Vaccination with Jf. melitentis Vaccine. 

1 . The subjects selected for yaccination and the results 115- 

2. Theyaccine 116^ 

8. The inoculations : 119- 

4. Clinical phenomena 120- 

6. Tabular details 121 

VIII. — Clinical Observations on Malta Fever 12a 

IX. — Conclusions and Recommendations ISO 

Preliminary Notes on Methods. 
A brief summary of the technique employed for the isolation and 
identification of M, melUensis, the performance of the agglutination 
test, and the selection of experimental animals, is inserted here in 
order to avoid unnecessary repetition in the body of the Report. 

Isolation of M. melitensis. 

1. Medium, — Nutrient peptone broth, prepared from Brand's Essence 
of Beef and standardised to +10 (Eyre's scale), was frequently 
used for the preliminary enrichment of blood, etc., but the medium 
generally employed for the isolation of M. nielitensis, and except where 
otherwise stated, was a nutrose-litmus-agar prepared on a basis of 
peptone broth, containing nutrose to the extent of about 1 per cent., 
tinted with litmus solution to an arbitrarily chosen colour standard, 
and standai^dised so far as concerns reaction to + 10 (Eyre's scale). 

This was the medium employed by the members of the Commission 
during the years 1904 and 1905; and although by no means the 
optimum medium, it was decided to continue its use throughout 1906- 
in order to render the results absolutely comparable with those of 
former workers. 



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Bacteriological and Uxperinienial Investigations, 1906. 5 

2. Method of CuUttre, — This medium was used in the fonn of surface 
" plates " — the liquefied agar being poured into Petri dishes, allowed to 
*' set," and, as a preliminary to inoculation, incubated for 24 hours at 
37^ C, so that any accidentally contaminated plates might be detected 
and discarded. In preparing plates, the infected material was 
deposited near the centre of the surface of the nutrose-agar and then 
distributed over the entire surface of the medium by the aid of a 
sterile L-shaped glass spreader. In the case of grossly-contaminated 
material, several plates were prepared in senes — that is to say, after 
the first plate had been inseminated the same spreader was employed 
to inoculate a second, then a third, and even a fourth and fifth with 
the traces of infective material still adhering to it — a method which 
yields dilutions comparable to those prepared by measuring with 
loopfuls when the liquefied medium in tubes is inoculated and then 
used for pouring plates. 

Incubation was invariably carried out aerobically at 37** C, and in 
those cases where colonies of M, mdiknsis had not developed by the 
second or third day, all plates were studied for at least seven days 
— except where the plates were so grossly contaminated as to be 
unworkable. 

Identijicaiion of M. melitensis. 

Suspicious colonies of cocci developing on these plates were first tested 
with serum derived either from patients suffering from Malta Fever 
or from experimental animals, in dilution of, usually, 1 in 100. Such 
as responded to this test and yielded a positive agglutination reaction 
were sub-cultivated in tubes of ordinary agar ( + 10), and the subse- 
quent growths, before being recorded as due to M, melitensis, were 
required to conform to the following criteria : — 

1. Size, shape, and Brownian activity f Corresponding to those 

2. Eeadiness and homogeneity of emulsioni ^^^'^^^^ by authen- 

l, tic type cultures. 

3. Non-retention of stain when treated by Gram's method. 

4. Production of alkaline reaction without change of consistency in 
litmus milk. 

5. Complete clumping when tested with specific agglutinating serum 
in high dilution : the dilution varied with the maximum titre of the 
serum employed, but was usually 1 in 1000. 

In many cases the cocci under examination were further tested as 
to their ability to produce M, melitensis septinrmia in the guinea-pig 
when inoculated intracerebrally. 

Performunce of Agglutination Reactions, 

The culture employed was invariably an early sub-culture grown on 
ordinary -h 10 agar in " sloped " tubes and usually for 24 or 48 hours 



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6 Dr. Eyre, Major McNaught, Capt. Kennedy, and Dr. Zanimit. 

at 37° C, from a strain of M, mditeiim that had recently been isolated 
from the animal body. Occasionally, but very rarely, it was found 
necessary to use three<lay-old cultures, but the use of such old cultures 
was discouraged as much as possible. 

The growth was emulsified in sterile O'l per cent, salt solution or ia 
sterile distilled water, in the proportion approximately of 0*5 miliar 
gramme of bacterial growth to 1 c.c. of fluid. 

The serum to be tested was diluted with normal saline solution and 
deposited in a series of small test-tubes. The dilutions prepared 
started with 1 in 5 (20 per cent.), and 1 in 10 (10 per cent.), and 
proceeded upwards in tenths of the first named — e,g,^ 1 in 50 (2 pep 
cent.), 1 in 500 (0*2 per cent.), and soon, so that when equal quantities 
of emulsion and diluted serum were mixed, dilutions of 1 in 10, 
1 in 20, 1 in 100, 1 in 1000, etc., were available for examination, 
other secondary dilutions, 1 in 50, 1 in 200, etc., being prepared and 
examined as occasion required. 

The examination was carried out both microscopically in the hanging 
drop, and macroscopically in sealed Pasteur pipettes — each method dt 
observation being carefully controlled by a blank preparation con- 
sisting of equal quantities of normal salt solution and emulsion ofi 
M. melittmsis. 

In the microscopical examination, the period of observation was 
limited to 30 minutes, and the result recorded as positive ( + ) when 
all the cocci were agglutinated into large clumps and none remained 
free in the fluid ; as incomplete ( ± ) when the clumps were small, and 
many cocci, singly and in pairs, were scattered about the field ; and 
as negative ( - ) when clumps were very small, comprising only a dozen 
or so individual cocci, or were completely absent. 

In the macroscopical examination, the period of observation was 
extended, if necessary, to 24 hours, and a positive result recorded only 
when the supernatant fluid was quite clear and all the cocci had 
sedimented into a compact mass at the point of the pipette ; a loose 
mass of cocci below and slightly turbid fluid above was returned as an 
incomplete reaction, and where the contents of the pipette closely 
resembled those of the control a negative reaction was recorded. In 
only a very few of the many thousands of preparations put up during 
the course of the summer did the macroscopical and microscopical 
results fail to control and confirm each other. 

Seleciion of Animals for Evypeiiinenial Work, 

Healthy animals, such as goats, kids, and monkeys, after purchase, 
were placed in the Lazzaretto as soon as they reached the Commission. 
Here they were tethered — out of reach of each other in the various 
stables and rooms which had been rendered fly- and mosquito-proof bjF 



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B€usteriological and ExperimerUal Investigations, 1906. 7 

GOTering the windows with fine gauze and supplying the doorways 
wiUi mosquito^etdng curtains — away from either infected animah or 
healthy animals already stabled there. The rectal temperature was 
taken night and morning; the blood repeatedly examined for the 
presence of specific agglutinins, and, in the case of milch goats, the 
milk examined for the presence of the Af. melUenm. Only when the 
temperature showed an absence of marked excursions from the accepted 
normal, and no evidence of infection with M, melUensia could be 
detected, w^re the animals regarded as "healthy and normal," and 
as soeh used for the experimental work of the Comnussion. 



I. — The Goat as a Factor in the Dissemination of 
Mediterranean Fever. 

1. The Distribution of Milch Goats Naturally Infected with M. melitensis. 

The work of the previous year in collecting information respecting 
the distribution of infected goats by examining herds from various 
parts of the island was continued as opportunity afforded in 1906. In 
the first place, the milk supply of various military centres and the 
village of Lia were investigated with the following results : — 

Table I. — ^The Proportion of Healthy and Infected Milch Goats in 
various Herds. 



Herd suppljing. 


No. of goats 
in he^d. 


Millr 
reaction in 


M. melitensis 
in m\\\ of 


Isfc Bi6e Briflnde 


46 
40 

38 
8 
60 
18 
86 


7 
10 
(3) 
12 



2 

6 

8 


1 
8 




1 



We§t Kent Ueflriment 


(Ite-examination of reacting goati)... 
Citta Yeoehia Sanatorium* 


Forrest HoeDitalf 


Imtarfa Hosnital 


Valletta Hoenitall 


Lia 


Total 


295 


45 1 8 

1 


1 

Pereentage 

• 






15-2 


2-7 


* The corresponding figures for 1905 
were 


15 
16 
18 


11 
5 
4 


5 
1 
1 


T 1, 1} >f 



The small number of goats (18 animals) examined in connection 
with Valletta Hospital comprised only about one-quarter of the 



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8 Dr. Eyre, Major McNaught, Capt. Kennedy, and Dr. Zamniit. 

goats actually suppljdng milk to the hospital, but the passive resistance 
of the goatherds in relation to the collection of samples, which was in 
no way overcome by the loud protestations of the contractor, resulted 
in the absence of the remainder of the goats whenever an attempt was 
made to collect specimens of milk. Within a few days of the examina- 
tion of this small portion of the herd a general strike of the goatherds 
supplying milk to Valletta was instituted and maintained from May 14th 
until June 1st, 1906. The strike lasted, in fact, until all the military 
hospitals and the majority of other large consumers had been compelled 
to replace their supplies of goats' milk by various brands of condensed 
or other tinned milk. Having thus forfeited their contracts and being 
no longer in the position of supplying milk to the hospitals and 
regiments, all hold over the goatherds was lost, and it was subsequently 
found to be impossible to complete these examinations in which a 
portion only of a herd had been investigated. 

A comparison with the results obtained in 1905* shows that the 
average number of infected animals, per herd, was much smaller than 
that noted when large numbers distributed over more extensive areas 
were dealt with, and forcibly illustrates the fallacy which would attend 
generalisations from the results obtained above. 

At the commencement of the season's work when comparing the 
incidence of Malta Fever upon the civil population of the island in the 
various local centres, the severity of this incidence upon certain villages, 
and the apparent absence of the disease from others closely adjacent, 
was particularly noticeable, and it was decided to carefully investigate 
the milk supply of Rabato, a suburb of Citta Vecchia, and to remove 
from time to time such goats as were found to be discharging 
M. melUensis in their milk from the herds examined, and study the 
eflFects of the removal of so much infective material from a restricted 
area upon the incidence of the fever. 

This plan was at once put into execution, and a preliminary examina- 
tion of the Eabato herds gave the following results : — 

Table II.— Infected Goats at Eabato. 



No. of herds 
examined. 


No. of goats 
examined. 


No. of milks 
reacting. 


No. of milks 

containing 

M. melitenns. 


40 


342 

Percentage 


52 


16 


16 


4-6 



• Vide Zammit, these Reports, IV, 96 et teq. ; Horrooks and Kennedy, IV, 
p. 87 et seq. 



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Bucteriologkal and Rtpenmcntal Imrstif/atioTis, 1906. 9 

At first all went well. Samples were readily supplied •and the 16 
infected goats were handed over by their owners for observation and 
treatment at the Lazzaretto, where each was supplied with a collar 
bearing a metal disc on which was stamped a serial number, to aid in 
the ready identification of the individual goats. The serial numbers 
commenced at 101 in order to avoid any confusion with experimental 
and other goats remaining at the Lazzaretto from previous years. (These 
animals were subsequently purchased at valuation and were utilised for 
experimental observations throughout the summer.) Soon, however, 
the influence of the goatherds' strike in Valletta spread to the provincial 
districts, and the goatherds of those villages in which operations were 
being carried on, refused in their turn to allow milk samples to be 
taken. 

Unfortunately, the local ordinances and statutes regulating the supply 
of food stuffs take little active cognisance of the goat as a source of 
milk, and proved totally inadequate — at any rate from a diplomatic 
istandpoint — to enforce compliance with the requests of members of 
the Working Party even when supported by sanitary inspectors, and the 
observations had perforce to be abandoned. The details of the 
examinations that were carried out are, however, inserted in Table III, 
because from them, incomplete though they are, emerge one or two 
suggestive points of more than passing interest. 

A subsidiary matter was to have been the investigation of those 
milch goats which, by the presence of specific agglutinins in their body 
fluids, gave evidence of infection, recent or remote, by M, melUensis, 
but whose milk did not contain the micro-organism. It was hoped 
that by a careful study of these animals some criteria might be arrived 
At by which it would be possible to determine whether the infection 
was so remote that the milk would remain innocuous, or so recent that 
the appearance of J/, meliteiim in the milk would be an ever-present 
•danger. 

This investigation likewise had to be temporarily abandoned with 
the larger experiment. 

During the course of the investigations, perhaps the most striking 
observation recorded was the healthy appearance of the majority of the 
infected goats. The animals were sleek and plump, with smooth, 
healthy-looking coats ; they took their food well, were as active as their 
uninfected fellows, and yielded as large a quantity of milk and of 
apparently as good a quality. Palpation failed to reveal any enlarge- 
ment of lymphatic glands or of alteration of the mammary gland. In 
many instances the infected milch goats were the best looking and the 
best milkers in the herd, and in a few instances only it was noted that 
^n infected animal suffered from a short barking cough at infrequent 
intervals. 

Perhaps the most noteworthy feature in the following table is the 



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10 Dr. Eyre, Major McNaught, Capt Kennedy, and Dr..Zammit. 
*Table III.—Ezamination of Herds at Babato. 



No. 

of 
herd. 



Name of owner. 



No. 

of goats in 

herd. 



No. No. of milks 
of milks j containing 
reacting. Jf. melxtensia. 



Cases of Malta 
Ferer on the 

premises during 
the current 
12 months. 



1 
2 
3 
4, 
6 
6 
7 
8 
9 
10 
11 
12 
13 
14. 
16 
16 
17 
18 
19 
20 
21 
22 
2» 
24 
26 
26 
27 
28 
29 
80 
31 
32 
33 
34 
35 
36 
37 
38 
39 
40 
41 
42 
48 
44 
45 
46 
47 
48 
49 



R Vassallo 

M. Borg 

r. Cutajar 

a. Mifsud 

G. Agius 

A. Micallef 

Qt. Vassailo 

P. D'AnatMs 

a. Ciantar 

G. Attard 

S. MicaUef 

L. MicaUef 

G. Galea 

G. Azzopardi .... 

L. Sant 

G. Attard 

P. MicaUef 

P. Sant 

G. Greoh 

G. Inguanez 

G. Micallef 

P. Micallef 

F. Galea 

G. M Azzopardi. 

S. Pace 

C. Formosa 

G. Micallef 

V. Azzopardi .... 

G. Vassailo 

P. Borg.A 

C. Borg 

G. Micallef 

G. Azzopardi .... 
A. Dimeoh 

F. Micallef 

P. Borg 

A. Dimech 

V.Borg 

C. Borg 

CarmeU Mifsud .. 

G. Zahra 

F.VassaUo 

F. PortelU 

S. Camilleri 

0. Calleja 

V. Attard 

P. Formosa 

C. Mifsud 

S. Dingli 



2 
2 

15 
3 

24 
4 
5 
3 
4 
2 
7 
4 
6 
5 

11 
8 
5 

22 
9 
5 
8 
2 

14 
7 

12 

13 
4 
7 
2 
4 
2 
1 

12 
6 
4 
1 
1 

17 

29 
9 

14 
5 
2 
2 
3 
5 
9 
4 







9 





2 

2 
8 
4 
2 

6 





1 
1 




1 
1 



1 








10 
2 
4 
4 






1 






* In dose association with next-door neighbour and relatire (G. Zahra), owner 
of Het4 No. 41, in whose house Are oases hare occurred. 



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Bacteriological and Ejypcrwunttal Invest i(/ation'% 1906. 11 

occurrence of one or more cases of Malta Fever during the present 
twelvemonth in the household of every owner of a milch goat, which , 
by reason of the isolation of the M, melitenm from its milk, was con- 
clusively proved to be infected, with one exception, viz., in the case of 
Herd No. 40, whose owner occupied the adjoining house to the owner of 
Herd No. 41. Here the two families and the two herds were intimately 
acquainted and in close daily contact, and in the house of the owner of 
Herd No. 41 no less than five cases of Malta Fever have occurred. 

This association of cases of Malta Fever in man with infected milch 
goats suggests in a striking manner the highly infective character of 
the milk cultivation — usually practically pure— of M, melUenm yielded 
by many of these milch goats, for the Maltese goatherd keeps his goats 
for profit and rarely uses goat's milk as a food for himself or his family ; 
and we are, personally, convinced from our enquiries and observations 
that, in the vast majority of cases occurring in goatherds and their 
families, infection is contracted during the handling of this food ky the 
direct inoculation of infected milk into cuts, scratches and abrasions on 
the face, hands, forearms, feet and legs of the individual. 

Cases were also present in some of the households where the herds 
contained milch goats, which, although yielding a positive agglutination 
reaction at the time of examination, were not passing the micro- 
organism in the milk. This, however, is no matter for surprise, and in 
no way militates against the views expressed above, for, as it will be 
mentioned later, it is not uncommon for a milch goat to yield milk one 
day containing more than 30,000 M. melitensis per cubic centimetre, and 
a few days later, milk apparently quite free from the microbe. 

It has already been stated that many of these herds at Kabato were 
examined more than once, some a second time three weeks after the 
preliminary examination, and a few on a third occasion a fortnight 
laW, before the milk vendors' strike became general. These re- 
examinations and their results are set out in Tables lY and Y. 

Inspection of these tables shows also the variation in size that indi- 
vidual herds undergo during comparatively short periods, in the present 
instances quite apart from the diminution in iiiunbers resulting from 
the removal of those goats whose milk yielded M. melitensis from their 
respective herds to the experimental stables at the Lazzaretto. 

The figures quoted were obtained by actual observation and by 
comparison with the Kegistration Books kept at the local police head- 
quarters; for a system is in vogue under which every goat owner 
reports, personally or by proxy, the number of goats in his possession 
every Saturday to the police. The number thus reported includes 
kids, male goats, and pregnant females not yielding milk as well as milch 
goatfl in full milk, the object of registration being to assist the Sanitary 
Service in the event of the occurrence of a^ epidemic of foot-and-mouth 
by calling attention to any diminution in the number of 



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12 Dr. Eyre, Major McNaiight, Capt. Kennedy, and Dr. Zammit. 
Table IV. — Re-Examination of certain Herds at Babato. 



No. of 
herd. 



No. of 
examination. 



No. of 
goats in herd. 



No. of ( 
milks reacting. 



No. of 

milks containing 

Jf. tnelUetuit. 



15 
16 
17 



19 



20 
21 



22 



24 



25 



27 



29 
80 



33 



40 



41 
45 



46 



48 



f First . 
\ Second, 
f First , 
\^ec•ond, 
r First , 
|_ Second, 
f First , 
\ Second, 
r First , 
\ Second, 
( First , 
\ Second, 
I F'irst . 
\ Second. 
fFirst . 
\ Second, 
I First . 
1, Second, 
r First . 
\ Second 
I First , 
\ Second, 
f First , 
(.Second, 
fFirst 
\ Second, 
I First 
\ Second 
f First 
\ Second 
r First. 
\ Second 
fFirst 
\ Second. 
fFirst , 
\ Second, 
r F'irst , 
\ Second. 
fFirst . 
\ Second. 
f First . 
'^Se^'ond. 
r First . 
\ Second. 
fFirst . 
\ Second. 
fFirst . 
\ Second. 



15 

10 

3 

a 

24 

15 

4 

3 

11 

11 

7 

8 

5 

5 

9 

6 

5 

2 

8 

7 

2 

2 

14 

» 

7 

5 

12 

12 

4 

4 

7 

7 

2 

2 

4 

5 

11 

10 

9 

6 

14 

10 

8 

2 

4 

4 

4 

4 







9 
6 


4 

1 
1 






2 
1 


1 


1 





1 




1 




1 


o 



4 
1 
4 
1 



n 






U 



4 
1 






1 


























o 



1 



1 






u 






.animals comprised in each herd. In practice, diuing the absence, as 
now, of epidemic foot-and-mouth disease, the system is useless, but the 
machinery at present in existence can undoubtedly be readily utilised 



Digitized by VjOOQ IC 



Bacttriohif/ica/ and £xpanmen(al Investigations, 1906. 13^ 

for that efficient system of registration of milch goats that the Local 
Government will be compelled to enforce if it seriously desires to stamp- 
ont Malta Fever from the island. 



Table V. — Third Examination of Certain Herds at Eabato. 


' No. of 
herd. 


^'o. of 
examination. 


No. of 
goats in herd. 


No. of 
milks reacting. 


No. of 

milks containing 

M, meliteiMis, 




fFirst 


5 
3 
6 

21 
21 
21 

4 
4 
4 
9 
11 
11 


8 

1 

6 

2 




1 





2 






1 









14 




18 
35 
47 


Third 


f First 


• Second 


Third 


fFint 


' Second 


Third 


fFirst 


< Second 




Third 







A further point, and one of considerable practical importance, depends 
upon the inconsistent results obtained at succeeding examinations, and 
is brought out in Table Y. Taking the herds in order, at the first 
examination of Herd No. 14, which comprised five milch goats, the milk, 
from three was foimd to give an agglutination reaction, and from two 
of these the micrococcus was recovered. These last two animals were 
removed to the Lazzaretto. At the next examination of the three 
remaining animals the one that had previously given a positive 
agglutination reaction still reacted, but the milk did not contain the 
coccus. At the third examination the owner had added two more milch 
goats, and none of the five reacted, that is to say, the reaction had 
disappeared from the animal that had reacted on two previous* 
occasions. 

Herd No. 18 consisted of 21 goats, including six whose milk gave a 
positive reaction. At the second examination none of these six reacted,, 
while at the third examination two of those which had previously 
reacted again showed the reaction, and the milk of one of them now- 
contained the specific coccus. 

Herd No. 35 consisted of four healthy milch goats, none of which 
showed any sign of infection at the subsequent examinations. 

Herd No. 47 consisted at first of nine goats, and the milk from one of 
them gave a positive agglutination reaction at the first examination,, 
but a negative reaction at the second and third examinations. Subse- 
quently the omnier added two healthy animals to his herd. 

These results show conclusively the necessity for repeated examina- 



Digitized by VjOOQ IC 



14 Dr. Eyi'e, Major McNaiight, Capt. Kennedy, and Dr. Zammit. 

tions at short intervals of every herd if the detection of all the infective 
.animals is aimed at. 

2. The Agglutirvation Test as Applied to the Milch Goat. 

The possibility that the Government of Malta might at some future 
period, should the infectivity of goats' milk be conclusively estab- 
lished, legislate on the subject, was fully appreciated in planning the 
observations on the milk supply of Eabato, and methods of examina- 
tion were carefully investigated with a view to simplifying and 
«ystematising the routine analyses of milk that would have to be 
undertaken by the Public Health Department in such a contingency. 

In the first place, there is no evidence that the ingestion of specific 
.agglutinins with the milk is, pei' se, injurious to health, and the 
legislature would undoubtedly require the recognition of the 
M, vielitensis itself in the milk as proof that such milk was noxious in 
character ; and as in the administration of any regulation dealing with 
niilk the frequent examination of a large number of animals would 
hiave to be undertaken, it became necessary to determine the simplest, 
most rapid, and most reliable method of sorting out the animals which 
were most likely to be passing the micrococcus in their milk before 
proceeding to attempt the isolation of the micro-organism by 
bacteriological methods. 

Such a method already existed in the milk agglutination test 
devised by Zammit and bearing his name, a test which depends upon the 
fact that M, melitensis agglutinins, like other specific agglutinins and 
antibodies when present in the body in sufficient quantity, pass into 
the milk, and t^ a less extent into the urine, and can be readily 
demonstrated in these situations. This test, it must be stated, has 
limitations which form its strong feature for the purpose with which 
we are at present concerned. 

The work carried out by the Commission in 1905 showed clearly 
that in presumably very remote or in very recent infections the 
presence of agglutinins could not be demonstrated in the milk, 
although they were present in the blood in sufficient quantity to yield 
a positive reaction in low dilutions when the blood serum was tested. 
On the other hand — and this is the point of practical importance — 
iff. melitensis has never yet been isolated, in the present series of experi- 
ments, from a sample of milk from which the specific agglutinin was 
absent. 

In its elemental form the test under consideration consists primarily 
of the admixture of equal parts of the suspected milk and an emulsion 
•of M, melitensis in normal saline solution. As originally devised, it 
was completed in one of two ways, either by making a hanging drop 
preparation of the mixture and observing it microscopically after the 
lapse of 12 hours, or by running the mixture into capillary tubes or 



Digitized by VjOOQ IC 



Bacteriological arid EayperimeTital Investigations, 1906. 15 

sedimentation pipettes, and observing macroscopically after a similar 
period. 

A reference to a previous part of these Reports (IV, pp. 55 and 
97 — 98) will show that a difference of opinion existed as to the best 
method of performing the test, some observers preferring the hanging- 
drop method, others the tube method. In point of fact, both had 
many disadvantages. 

In the microscopical method, quite apart from the difficulty of 
entirely preventing evaporation when the period of observation 
continued for so long a time as 12 hours, the difficulties introduced by 
the presence of masses of varying sized oil globules, which obscured 
all but the very large clumps, were considerable, and in the event 
of observations being made by partially-trained observers would 
undoubtedly lead to inaccurate results. These considerations early 
led to the rejection of this form of the test as a practical measure. 

The macroscopical method was next studied, and as the perfect 
emulsification of the fat which obtains in goats' milk was undoubtedly 
the cause of the disfavour with which the test was received, a low 
dilution of 1 : 3 was first employed. In this series of tests numerous 
observations were made, carefiilly checking the naked eye results by 
running the deposit out of the capillary tube or sedimentation pipette 
and examining it microscopically. It was soon found that when 
results recorded at five hours were taken this method was a satis- 
factory and reliable one, but when tubes were left standing overnight 
the results noted in the morning were as often as not fallacious owing 
to the formation of a bulky deposit consisting of ddbiis, leucocytes, etc., 
and not of clumps of M. melitensis. 

Next was tried the effect of first converting the milk into curds and 
whey by the addition of rennet or of acid, separating off the curds and 
testing the whey. A number of experiments were made simiil- 
taneously with various samples of milk, and with whey prepared from 
each sample, and it became at once apparent that the agglutinins, 
unaltered, were present in the whey. The whey reaction was given 
equally well, was as definite as with clear serum, and obviously 
no confusion could arise with regard to pseudo reactions, due to the 
collection of cUbr^, so that apart from the extra time and labour 
involved in preparation, the whey gave eminently satisfactory resiilts. 

On subsequently plating, however, it was found that cultivations 
prejwred from whey jrielded only about 10 per cent, of the number of 
micrococci developing from the corresponding milk sample after an 
identical period of incubation, a result possibly due to retention of 
cocci in the curd, possibly to destruction of cocci by acid. 

Further dilutions of the milk itself were then tried, and finally it 
was determined that the most trustworthy and convenient method 
was to employ a dilution of 1 : 20 in capillary tubes or sedimentation 



Digitized by VjOOQ IC 



16 Dr. Eyre, Major McNaught, Capt. Kennedy, and Dr. Zammit. 



Table VI. —Comparison of the Agglutination Value of 



Date ... 
Dilution 



July, 21, 1906. 
1 : 20 1 : 50 1 : 100 



July 24, 1906. 
1 : 20 1 : 50 1 : 100 



July 26, 1906. 
1:20 1:50 1:100 



July 28, 19< 
1:20 1:60 1 



€k)at 101— 

Milk 

Serum ... 

Goat 102— 

Milk 

Serum ... 

Goat 108— 

MUk 

Serum ... 

CUmt 104— 

MUk 

Serum ... 

Goat 105- 

Milk 

Serum ... 

Goat 106— 

MUk 

Serum ... 

Ooat 108— 

Milk 

Serum 

Goat 110— 

Milk ' -»■ 

Serum ] + 

Goat Ill- 
Milk ' + 

Serum ' + 

Goat 112— I 

Milk I + 

Serum — 

Goat 118— 

MUk ' + 

Serum ' + 

Goat 114^ I 

Milk ' + 

Serum | + 

Goat 115— 

MUk ' + 

Serum ' ± 

Goat 117— 

Milk + 

Serum + 

Goat US- 
Milk ' + 

Serum + 

Sheep 107— I 

Milk 

Serum , 











+ 
+ 

+ 
+ 



± 

+ 



± 
± 






+ — 
± - 



+ — 
+ — 



+ 
+ 



+ — 
+ + 













+ 
+ 



+ 
+ 



+ 
+ 



+ 

+ 











+ 



4 

+ 



± 

+ 



+ — 
+ — 



+ 
+ 



+ 
+ 



+ 
+ 



+ 

+ 



+ 


















' not examined. 



Digitized by 



Google 



Bacteriological and RjoperimerUai Investigations, 1906. 17 



lod Blood Serum in the Infected Milch Otoat and Sheep. 






J1I7 91, 1906. 
1 1:801:60 1 : 100 


Augnrt 2, 1006. 
1 : 20 1 : 60 1 : 100 


AxLffast 4, 1006. 
1 : 20 1 : 60 1 : 100 


Augntt 7, 1906. 
1 : 20 1 : 60 1 : 100 


i 




+ — - 
+ + + 





• 

+ + 

+ — 


- 





+ + — 





+ ± 


± 





_ _ _ 


n 


+ + 


. 


+ + — 


V 


+ + 


+ 





+ - - 





± ± 
+ + 


+ 





+ — — 
+ — — 





+ + 


— 





+ + — 
+ + + 





+ — 


— 





+ — — 





+ + 


+ 


+ • + + 


+ + 


+ 


+ — — 


o 


+ + + 


A 




+ + + 


V 


+ + + 


V 




■H 1 

+ 1 





+ + ± 

+ + + 







■- - - 





+ — — 







♦ + + 


Q 


+ + + 


o 




+ + + 




+ + + 


\r 




•f — — 


ri 


+ + + 


A 




+ + + 


V 


+ + + 


V 




+ i ± 


Q 


+ + + 


n 




+ + + 




+ + + 


\f 




1 : : I 





+ + - 
+ + + 







1 

+ + + 





+ — — 
+ - — 







f) 


± - - 





+ + 


+ 


V 


+ + - 




+ + 


+ 


r 


- not exi 


umined. 







(13984) 



Digitized by VjOOQ IC 



18 Dr. Eyre, Major McNaught, Capt. Kennedy, and Dr. Zammit. 

pipettes with a time limit of 24 hours — a method carried out in actual 
practice by mixing equal volumes of a 1 : 10 dilution of milk with the 
previously prepared emulsion of if. inelUensis in distilled water. Under 
these conditions the fluid is sufficiently clear to show the reaction 
quite as definitely as in the case of blood serum, while the specific 
gravity is so altered that the fat globules are very quickly disentangled 
and rise -to the upper part of the column of fluid as cream, and the 
risk of pseudo reactions from sedimentation of dSbris is avoided. 

By repeated experiments it was found that where a true reaction 
was yielded by the low dilution method (1 : 3), a reaction was 
obtained in 1 : 20 dilution ; but on carrying the dilution higher it 
was found that milks giving a positive reaction in 1 : 3 and in 1 : 20, 
and which on plating yielded if. melitensis in some instances, gave 
a negative reaction in 1 : 50. 

Moreover, it was found that in the case of sheep the low dilution 
(1 : 3) did not give reliable results owing to the opacity of the milk ; 
whilst with a 1 : 20 dilution consistent and reliable results were 
obtained. 

The test as thus modified has now been in use for many months, 
and the best criterion of its utility is summed up by the fact that 
M, meliiensis has never been isolated from or. detected in a sample 
of milk which yielded a negative reaction. 

It was also noted during the course of these experiments as a 
general, but far from invariable, rule, that those milks which gave 
a good sedimentation reaction immediately upon mixing with the 
bacterial emulsion, or within an hour or two, were more likely to yield 
cultivations of if. vielitensis on plating than those which required the 
full 24 hours for the completion of the reaction. 

A comparison of the milk agglutination reaction with the blood 
agglutination reaction of the infected goat naturally formed part of 
these experiments with the " Zammit test." 

The milk and blood samples were collected at the same time, the 
test applied with the same bacterial emulsion, and identical dilutions 
of 1 : 20, 1 : 50, and 1 : 100 were employed in each case. 

Roughly speaking, the reactions are comparable : on the whole the 
blood frequently reacts in higher dilutions than the milk, though in 
some instances the opposite holds good. In two animals (Goats 
Nos. 106 and 112) the milk reacted in 1:20 when agglutinins 
appeared to be absent from the blood ; in a third (Goat No. 103) the 
converse obtained, the milk did not react in 1 : 20, while the blood 
did so. No relationship whatever could be deduced between the 
intensity of the reaction and the numbers of if. inelitensis present in 
the milk. A number of these observations are tabulated on pp. 16 
and 17. 

The table shows, too, in a most marked manner, the periodic 



Digitized by VjOOQ IC 



Brteteriological and E^periinenial InvestigationSy 1906. 19 

variation in the agglutination value of the serum, the curve of which 
is closely followed by that of the milk, due no doubt to auto-inocula- 
tion or auto-vaccination with living M, melUensis taking place in 
milch goats which are still the subject of a subacute systemic and 
generalised infection — an explanation which accords well with 
observed facts, and which is supported by the results of observations 
made upon milch goats which were under treatment with vaccine 
prepared from dead cultures of M. melUensis, 

3. The Numerical Jtelationship of M. melitensis to iJie Milk of 
Infected Goats. 

As it had already been noted that the milk from an infected goat 
varied greatly from day to day in its potentialities for evil — that is to 
say, milk which contained many thousands of individual M. melitensis 
per cubic centimetre when examined one day, at the next examination 
a few days later, or even on the following day, might be apparently 
free from the micro-organism, and again in a few more days might be 
crowded with the cocci — systematic observations were commenced to 
determine, if possible, whether some definite periodic variation, seasonal 
or otherwise, existed. These observations are as yet incomplete, but 
the results of nearly four months' work are available, and on account 
of their interest are inserted here. 

The results show that although the excretion of M, 7)ielite7isis in the 
milk during some stages of the infection is persistent, it is by no means 
constant or even consistent ; nor — premising that all the observations 
now recorded were carried out during the so-called summer — was it 
possible to determine any correlation between the temperature curve and 
the number of cocci excreted in the milk (vide Fig. 2, p. 24). The 
observations which are being continued throughout the winter may, 
however, afford further information in this connection when completed. 
The animals affording material for the enquiry were comprised in a herd 
of 17 milch goats and 1 milch sheep belonging to the Commission and 
stalled in the Lazzaretto. Twice and often three times a week a specimen 
of milk was collected from each animal, immediately conveyed to the 
Laboratory at Valletta, and there plated out. On accoimt of the 
extreme variation noted in the numbers developing per cubic centimetre 
from each animal's milk, together with the necessity for examining the 
milks from a number of animals each day, it was a matter of some 
difficulty to decide on the amoimt of milk to be plated for each 
examination. After many experiments in this direction 0035 c.c. — 
an amount equivalent in bulk to a single drop falling by gravity from 
the end of a fine capillary pipette — was decided upon, and three plates 
were inseminated, each with this quantity of milk, from every goat at 
each examination. In plating, the milk was deposited on the centre of 
(13984) c 2 



Digitized by VjOOQ IC 



20 Dr. Eyre, Major McNaught, Capt. Kennedy, and Dr. Zammit. 

a nutrose-agar plate and distributed all over the surface by means of 
a sterile L-sliaped glass rod spreader. After suitable incubation, the 
colonies of M. meliiensis that had developed on each of the three plates 
were enumerated and averaged, the contents per cubic centimetre 
calculated and the results obtained recorded in tabular form, and also 
plotted in a curve. 

Table VII. — Numerical Strength of M. melitensis per cubic centimetre in Mil 

Infected Goats. 



Serial No. of 












I 




1 


goat 


104. 


105. 


106. 


107. 


111. 


112. 


114. 


115. ; 

L. 


1906— 




















May 7... 


4,000 


bU 


880 


7,000 


— 


— 


— 


— 




„ 10... 


800 


80,000 


200 


? 


15,000 


100 


— 


— 




„ 15... 


18,000 


nil 


nil 


2,400 


6,000 


nU 


— 


— 




» 22... 


80,000 


nU 


nil 


6,000 


80,000 


nil 


— 


— 




„ 26... 


8,000 


ml 


nU 


4,000 


6,000 


4,000 


— 


— 




„ 29... 


30 


nU 


nil 


4,600 


16,000 


nU 


— 


— 




,. 81... 


ml 


nil 


nil 


6,500 


80,000 


100 


ml 


6,000 




June 2... 


66 


nil 


nil 


10,000 


5,700 


nil 


80,000 


16,000 




„ 6... 


7,500 


nil 


nil 


6,000 


12,000 


30 


4,300 


80,000 


3< 


„ 9... 


nU 


ml 


nil 


ml 


20,000 


nU 


? 


4,600 




„ 12... 


830 


ml 


nil 


7,800 


8,400 


66 


nil 


80,000 


8C 


„ 14... 


nil 


5,000 


nU 


10,000 


8,000 


100 


1,760 


6,500 


8( 


„ 16... 


66 


nil 


nil 


600 


6,000 


30 


14,000 


100 




„ 19... 


nil 


nil 


nil 


nil 


80,000 


700 


700 


430 




„ 21... 


30 


nil 


nil 


80 


2,400 


2,000 


ml 


28,000 




.. 23... 


180 


nil 


2,000 


6,000 


2,700 


3,200 


1,600 


660 




,, 26... 


66 


nil 


2,000 


16,000 


18,000 


80,000 


20,000 


1,000 


1 


„ 28... 


200 


nil 


nil 


80,000 


12,000 


2,600 


16,000 


2,600 


2 


„ 30... 


1,600 


30 


400 


80,000 


23,000 


1,000 


18,000 


4,700 


S 


July 3... 


1,100 


nil 


330 


8,000 


6,170 


66 


16,000 


8,000 


8< 


„ 6... 


400 


nil 


30 


2,400 


4,000 


66 


20,000 


17,000 


S 


„ 19... 


700 


10,000 


nil 


23,000 


— 


— 


— 


— 




,. 21... 


— 


— 


— 


— 


730 


nU 


15.000 


80,000 


8C 


„ 24...I 


470 


8,800 


nil 


2,800 


— 


— 


— 


— 




„ 26... 


— 


— 


— 


— 


1,000 


nil 


4,000 


20,000 


2 


„ 27...; 


— 


— 


— 


— 


4,000 


— 


800 


800 




„ 28... 


66 


nil 


ml 


1,700 


— 


— 


— 


— 




,. 31... 


— 


— 


— 


— 


80 


nU 


80,000 


1,700 


1 


Aug. 2... 


16,000 


1,200 


nil 


1,800 


— 


— 


— 


— 


2 


„ 4... 


— 


— 


— 


— 


2,700 


nil 


3,000 


780 




„ 7... 


660 


6,300 


100 


1,000 


— 


— 


— 


— 




„ 14...I 


1,600 


nil 


540 


20,000 


nil 


nil 


nU 


8,000 


8G 


„ 18... 


750 


6,600 


nil 


720 


10,000 


nil 


6,000 


nil 





— =a not examined. 

In connection with this table a fallacy and an inaccuracy must be 
pointed out. In the first place, the fallacy consists in recording nil 
per cubic centimetre, when only three separate small amounts of milk 
— totalling in the aggregate but a little more than 0*1 c.c. — ^proved to 
be sterile or had failed to give rise to a single colony of M, melitensis. 



Digitized by VjOOQ IC 



Baeteriological and Experimental Investiffotions, 1906. 21 

Such a reeult, however, is amply sufficient to show that the if. meU- 
tensis ccmtent of the milk is extremely small, and, bearing this fallacy 
in mind, it is sufficiently accurate for the purposes of a comparative 
table to record such a result as nil. The inaccuracy relates to the other 
extreme. In enumerating colonies on a plate it is usual to count each 
individual colony, when the number does not exceed 1,000, by the help 
of radii drawn on the bottom of the glass dish with a grease pencil. 
Beyond this figure it is customary to observe the colonies by the aid of 
a low power objective, to enumerate those enclosed in several areas of 
the plate, and average the contents of such areas. For this purpose a 
1-inch or a f-inch objective, a suitable eye-piece and such particular 
length of tube is employed as will produce a field whose area bears a 
definite relationship to the total area of the plate, so that finally the 
approximate content of the entire plate is rapidly calculated from the 
content of an average field. The recorded figures between 100 and 
1,000 may therefore be regarded as accurate ; figures in excess of 1,000 
calculated from the average contents of selected microscopical fields are 
probably highly inaccurate; but as in all these estimations care was taken 
to select the fields for counting from the least crowded portions of the 
plates the inaccuracy was always in the direction of underestimation. 
In some instances so obvious was the underestimation that 30,000, the 
highest figure recorded — as it was necessary to keep the curves that are 
presented herewith (see Fig. 2) within reasonable limits — is indicated 
in special type to show that, in the opinion of the observers, at least 
one other zero should be added, as the numbers were practically 
uncountable. 

This difficulty in enumeration will be better appreciated by a glance 
at Fig. 1, which represents a plate inoculated with 0*035 c.c. of milk 
from Gk)at No. 111. With the exception of the few large colonies of 
saprophytic bacteria, all the colonies are due to the growth of 
if. melitensis. The milk from which this plate was prepared is returned 
as containing 30^000 M. melUensis per cubic centimetre. 

On several occasions control plates were prepared with suitable 
dilations of the milk samples, and it was frequently found that 
3,000,000 per cubic centimetre would be much nearer the true content 
of the milk than the 30,000 recorded. 

In this connection it may be remarked that the conditions under 
which work with goats' milk is carried out in Malta are totally 
different from those that hold in England, when the corresponding 
food, cows' milk, is being investigated. It must be obvious to those 
who are in the habit of working with cows' milk at home, that the 
enumeration of colonies of any specific organism, e.g., streptococci, in 
plates prepared by smearing milk direct upon the surface of the 
medium, would be a hopeless task on account of the number of 
extraneous saprophytes present. With the Maltese goat, however, 



Digitized by VjOOQ IC 



22 Dr. Eyre, Major McNaught, Capt. Kennedy, and Dr» Zammit. 

having discarded the first few cubic centimetres of fore milk, the next 
quantum, the mid 'milk and the stoppings, consist of sterile, or 
practically sterile, milk, in the case of the normally healthy milch goat, 
or a pure culture of M, inelitem^u in the case of the milch goat which 
is infected by M, melilensis and is voiding the germ in its milk. Some 
of the reasons for the clean character of the milk are fairly patent. 



Fig. 1.— Nutrose agar plate prepared from 0*035 c c. freshly drawn milk from Gt»t 111. 
All the minute colonies are composed of Jf. melifensis. 

although the goat is an extremely dirty animal in its choice both 
of food and resting-place. Most important of all is the fact that the 
milk is examined within a very short time of its removal from the 
mammary gland of the goat — no long interval, occupied in transit 
by road and rail, is allowed for the multiplication of extraneous 
saprophytes. Again, in milking, the goatherd invariably crouches 



Digitized by VjOOQ IC 



Barieinologica/ and Experimental Investigatwus, 1906. 23 

directly behind the animal, and grasping the udder, drags it back 
between the hind legs, which the animal separates widely to allow of 
its passage. The receptacle for the milk, if small, is held in one hand 
some distance behind the animal and below the level of the teat, while the 
other hand, grasping udder and teat, directs an oblique stream of milk 
into it — ^in other words, the jet of milk and the receiving vessel hold the 
same relative positions as the inoculating platinum needle, and the test- 
tube respectively, when a tube culture is being prepared in the labora- 
tory. If the receptacle for the milk is large, it is placed on the ground 
behind and well clear of the goat, and the goatherd, emplo3ring both 
hands, milks from both teats ; consequently, any dirt and filth dropping 
from the udder and hindquarters falls more or less vertically to the 
ground, while the stream of milk traverses a stratum of clean air which 
does not usually add saprophytes to the milk ' during its passage ; 
indeed, the freedom of the air and dust from saprophytic bacteria is a 
noteworthy feature of bacteriological research in Malta, and is due no 
doubt to the sterilising action of the direct rays of the sun — which are 
available for at least 12 hours per diem for the greater part of the year. 
Aerial contamination of cultivations in a laboratory kept moderately 
elean is rare, plate cultures can be made in the open air with a 
reasonable certainty that, where not intentionally infected, they will 
remain sterile, and plates may be opened and examined day after day 
without the preparations becoming contaminated. 

For the moment the only explanation that can be offered of this 
day-to-day variation in the number of cocci present in the milk is 
Uiat the micro-organism, lodged in a suitable soil and richly supplied 
with a medium of high nutritive value, multiplies rapidly in the 
interstices between and upon the surface of the gland epithelium cells. 
This multiplication proceeds up to a certain point, when, owing perhaps 
to the mechanical irritation set up by the mere presence of the coccus, 
a flushing process is carried out by the milk itself which removes the 
ffjDcess of cocci and leaves behind in the gland tissue only those cocci 
which are in intimate relationship with the gland cells. A certain 
interval necessary for the further multiplication of those cocci left 
behind elapses, then the process is again repeated, and so on. 

Ck)nversely, it is more than probable that the stimiilus provided by 
the presence of the bodies of the cocci, or of their toxins, is an 
important factor in the large and long-continued milk yield of the 
infected milch goat. 

In the accompanying Graph, the numbers of M. nidUensis obtained at 
the periodic examinations of the milk from Goats 111, 114, 117 are 
plotted out in curves superposed on the curve representing the 
diurnal mean temperature of the air of Valletta. On the one hand, it 
will be seen that there is no direct association between discharge of 
cocci in the milk and rise or fall of air temperature ; on the other, the 



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24 Dr. Eyre, Major McNaught, Capt Kennedy, and Dr. Zammit. 




TTT. 

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Bacteriological and Eocperimental Invedigatiom, 1906. 25 

periodic discharge of large quantities of cocci and the variable interval 
during which but few cocci are present in the milk, are well brought 
out. 



4. The Presence of M. melitensis in MUk Products, 

The fact elicited as the result of the examination of a very large 
number of animals, that at least 10 per cent, of the milch goats in 
the Island of Malta secrete milk which contains the specific germ of 
Malta Fever in divers quantities, rendered it extremely likely that 
the micrococcus might pass unscathed through the various manipula- 
tions to which milk is subjected in the preparation of articles of food 
such as cheese, etc., and some observations were accordingly made in 
this connection. 

Cheese, — The native cheese in common use is a whole milk cheese, 
and is prepared in a very simple and primitive manner. Acid or 
rennet is added to the sheep's or goat's milk, and the resulting curd 
is " set " in open basketwork moulds which allow the whey to drain 
off, placed aside overnight, and is ready for consumption the following 
day. Such a cheese is, of course, eaten fresh, as its method of 
preparation hardly fits it for prolonged storage. 

At first sight it would appear probable that the high degree of 
acidity present in the cheese (a fair average would be + 80 or + 90 
as compared with an optimum of + 8 or + 10 aimed at in preparing 
nutrient media for the cultivation of M, melitensis) would ensure the 
destruction of the micrococcus. A reference, however, to the work 
of Shaw* shows that the micrococcus can retain its vitality in urine, 
having a reaction of + 40, + 50, or + 60 ; and, again, it was noted 
in carrying out certain experiments as to the presence of agglutinins 
and of the specific coccus in whey, prepared from infected milk, that 
the coccus retains its vitality in this highly acid whey, while the 
diminution in number in this whey as compared with the original 
milk would suggest that numerous cocci remain entangled in the curd, 
quite as much as that numerous cocci are killed off by the acid present. 

The first sample of cheese to be examined was obtained 24 hours after 
setting, direct from its manufacturer, a peasant farmer near Zebbug, 
who kept a herd of 13 milch goats and one milch sheep. (Seven of 
his goats, the sheep and a sow were subsequently found to be infected, 
and the goats and sheep were secreting milk containing M. tnelitensu. 
These animals, purchased by the Commission and lodged in the 
Laszaretto, afforded material for many of the observations recorded in 
the previous pages.) 

Plate cultivations in series on the surface of nutrose-agar were 
established in the usual way from pieces cut from the centre of the 

• Thefe Beports, III, p. 43 et seq. 

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26 Dr. Eyre, Major McNaught, Capt. Kennedy, and Dr. Zammit. 

cheese with a sterile knife, after well searing the surface with a red- 
hot iron : and also from 0*1 c.c. of an emulsion prepared by breaking 
up approximately 01 gramme of cheese in 10 c.c. of sterile broth. 
Three plates only were prepared in each series, and after incubation 
it was foimd that the dilution was insufficient, as all were crowded 
with saprophytic bacteria which rendered the " fishing " of the colonies 
of M, meliiensisj which were recognised with the hand lens, a matter 
of impossibility. Scrapings from the plate, which included colonies 
of the coccus as well as neighbouring saprophytes, when emulsified 
in distilled water and added to a 1 in 250 dilution of specific serum, 
showed microscopically typical clumps of M, mdiiensis. Ordinary 
sub-cultures failed to give a growth of the micrococcus, and as it was 
considered waste of time to continue work on this cheese, the plates 
were abandoned and further experiments made with cheeses prepared 
in the Lazzaretto from the milk of the identical infected sheep and 
goats — now the property of the Commission — from which this first 
specimen had been manufactured. 

Nmnerous cheeses were made and each examined repeatedly during 
several days, and it was found that by careful attention to the 
question of dilution in preparing the series of plates, it was a fairly 
easy matter to isolate the coccus from the cheese up to the end of 
48 hours. After this time the multiplication of lactic acid and other 
bacteria outstripped that of M. mditeTisis^ and it was no longer possible 
to recover the organism. 

Ice Cream, — With the advent of hot weather, soon followed by the 
iliscovery that the ordinary private soldier does purchase ice-creams 
in the local caf^ and consume them, attention was directed to this 
milk product. Enquiry elicited the fact that, as in England, two 
varieties of ice-cream are in vogue, the one prepared by freezing a 
flavoured custard of milk and eggs previously heated to about 80** or 
90'' C. and cooled, the other by flavouring milk to which cream may 
or may not be added, with various essences or syrups and freezing* — 
the former being the more expensive. As by this time the infectivity 
of goats' milk was becoming a matter of common knowledge among 
the Restauranteiu-s of Malta, one individual volunteered the information 
that he always boiled his goats' milk before using it in the manufac- 
ture of ice-cream. On the other hand, it has been stated by a private 
in the Royal Army Medical Corps that a caf^ keeper who had run out 
of his stock of ices would milk the goat tied up to his door post, and 
some 20 minutes later produce the ice-cream to his customer. 

Experimental ice-creams of both types were, therefore, prepared 
in the laboratory from milk derived from the infected herd at the 
Lazzaretto, and then examined for the presence of the M. meliieim^. 
In the case of those made from a custard of milk, eggs, and sugar, 
and heated to about 80** C. to ensure the thorough incorporation of 

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Bactei^ologicnl and Expet'inieiitcd Investigaiioiis, 1906. 27 

the ingredients, it was found impossible to recover living M, mdiiensisy 
although it was known they were present in abundance in the infected 
milk — ^from the result of plate cultivations established prior to 
heating. This was only to be expected, as the thermal death point 
of the organism in watery suspension has been determined as 67 'b"" G. 

In the case, however, of the second type of cream where no heating 
is resorted to, it was found to be as easy to recover M. meUiensis 
from such as had been prepared from infected milk as it was from the 
milk iuelf. 

With these data to work upon, a series of examinations of samples 
of ices from various caf^s was instituted. The ice-cream, on arrival 
in the laboratory, was placed in the incubator at 37" C. for an hour 
or two to thaw. The ortol and peroxide of hydrogen test* was next 
applied to determine whether or no the milk had been boiled or had 
been heated above 70** C, although often ocular observation was 
sufficient in the case of such as had been prepared from custard. 
In the event of the sample of cream having been made from custard, 
the specimen was, of course, discarded, but if it responded to the 
test and gave the characteristic reaction associated with unheated 
milk, then plate cultivations in series were established from the cream 
and set aside in the incubator. Some of the fluid portion of the ice- 
cream was diluted to 1 in 10, with sterile water added to an equal 
quantity of emulsion of M. inelitensis, taken up in sedimentation tubes 
and set aside for observation as to the presence or absence of 
agglutinins. 

If, on the following morning, the sedimentation reaction was 
absent, the plates made from that particular ice-cream were discarded, 
as previous experiments in this connection (p. 18) had shown that 
M. meliiensis was never recovered from milk in the absence of a good 
agglutination reaction in dilution of 1 in 20. 

In all, 1 1 samples of retail ice-creams were examined before illness 
interfered with the investigation. Three had been prepared from 
heated custard, and were consequently discarded; four others, pre- 
pared from unheated milk, were plated out, but as on the following 
morning the sedimentation reaction was absent, these plates were not 
proceeded with. The four remaining samples — made from unheated 
milk — yielded a complete sedimentation reaction, and the plates 

* This its a test introduced by Saul some few years ago, and depends upon the &ot 
thftt the addition of ortho-methyl-aminophenol sulphate (or of ortol, an impure 
preparation of the same salt, used chiefly in photographic work) to raw milk in the 
preecnce of nascent oxygen, gives rise to a brick-red coloration within 30 seconds of 
mixing. With milk which has been heated at or above 7(f C, no change is observed. 

In practice the test is carried out by adding 1 c.c. of a freshly prepared aqueous 
solution of ortol (1 per cent.) to 10 c.c. of milk in a test-tube and then adding one or 
two drops of hydrogen peroxide (3 vols.). 



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28 Dr. Eyre, Major McNaught, Capt. Kennedy, and Dr. Zammit. 

prepared from them were carefully worked out, but with negative 
results ; M. melitensis could not be detected. 

Further investigations in this direction are now in course of 
prosecution. 

Butler, — As practically all the butter consumed in the island is 
imported tinned butter and margarine, no examinations of samples of 
this food were made. 



5. Susceptibility of the Goat to, and Paths of Infection by M. melitensis. 

As the results of the examination during the years 1905 and 1906 
of a very large number of animals scattered throughout the island 
had revealed the fact that, roughly, some 10 per cent, of the milch 
goats were secreting milk containing the coccus, while some 30 per 
cent, more by the existence of fair quantities of specific agglutinins 
in the blood serum and milk afforded the strongest presumptive 
evidence of previous infection, it is obvious that the goat is distinctly 
susceptible to the pathogenetic influence of M. melitensis. The experi- 
mental work carried out during the same years also showed clearly 
that the goat could be infected, with a fair amount of ease, by the 
ordinary laboratory methods of inoculation — that is by the sub- 
cutaneous and intravenous injection of living cultivations of 
M, melitensis — and also by feeding, either with artificially or naturally 
infected material. 

These observations rendered any extended series of experiments in 
similar directions needless; on the other hand, no experimental 
results were available with regard to infection by contact, such as had 
already been shown took place in the case of monkeys in close proximity 
to each other.* 

Contact Infection. — Two yearling female goats — Nos. 22/5 and 23/5 
— which had not yet been impregnated, and consequently were not 
**in milk," and from whose blood specific agglutinins were absent, 
were, therefore, turned loose into a large stable in company with 
16 infected milch goats and one infected milch sheep, from all of 
whose milk M. melitensis was obtainable in varying niunbers. None 
of the animals were tethered; consequently the contact was as 
intimate as possible, while the fact that neither of the two experi- 
mental animals were included in the daily milkings eliminated the 
likelihood of transmission of infection vi& the goatherds' hands. 
Eight days after the commencement of the experiment the blood 
serum of Goat No. 23/5 yielded a partial agglutination reaction in a 
dilution of 1 in 10 ; on the following day the serum from Goat 
No. 22/5 gave a similar result, and on the 16th day both goats gave 
a complete positive agglutination reaction in dilutions 1 in 10 and 

• ride these Reports, I, p. 67. 

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Bacteriological and EjoperimerUai InvedigaiionSy 1906. 29 

1 in 20. Subsequent examination of the blood serum from each goat 
showed those fluctuations of the agglutination curve that are usually 
associated with M, melUensis infections, and the senun value six weeks 
after the commencement of the contact reached 1 in 100. At the 
end of four and a-half months both goats were killed and examined 
post-mortem. The organs that were examined after death were spleen, 
inguinal glands, mesenteric glands, and kidneys, and from none of 
these was if. mditensis recovered. This failure to detect the specific 
micro-organism post-mortem in the case of infected goats has by no means 
the same significance that it would have in other experimental animals, 
a point which will be referred to in a succeeding section. 

In this experiment infection may have taken place through actual 
contact, the ingestion of fodder saturated with infective milk or urine, 
convection by ordinary flies, transmission of the coccus by means of 
biting flies, etc., the conveyance of infective material on the goatherds' 
hands alone being eliminated. 

Of the various methods above mentioned, it may be pointed out 
that some would be excluded imder ordinary circumstances. For 
instance, in the native goat-house the goats are usually tied up on 
either side of a raised trough containing food, from which few or 
many feed in common, by a length of rope sufficient to permit of the 
animal lying down. Each animal retains the same position from day 
to day; consequently contact in the stable is limited to the neigh- 
bouring goats on either side, and when the troughs are arranged in 
rows to the animal immediately behind also, and it is a noteworthy 
fact that in many cases it is either the next-door neighbour or the 
goat immediately behind the infected goat that next becomes infected, 
and not the goat on the opposite side of the trough. When taken 
out of the goat-house to start on the daily milk round, contact is 
more promiscuous, though here, again, stable companions are said to 
keep together. 

Stibcuianeom Infection, — It next appeared desirable to determine 
whether comparatively small doses of living cocci from artificial cultiva- 
tions could be depended upon to produce infection. For this purpose 
four normal, healthy, yoimg kids were selected, and when repeated 
observations had shown that specific agglutinins were absent from the 
blood, they were injected subcutaneously, each with a different sized 
dose of infective material. 

The strain of M. m>elitensis employed for the experiment was a first 
sub-culture (from a single colony) of the coccus isolated from the milk of 
Goat No. Ill — one of the infected milch goats under observation in the 
Lazzaretto. 

The actual culture used was a 48-hours agar-tube growth. One loopf ul* 

* An ordinary agar slope cultiyation would be equivalent, approximately, to 
50 such loopfuls. 



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30 Dr. Eyre, Major McNaught, Capt. Kennedy, and Dr. Zammit. 



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B(ust€riologicid and Ex'perime/tital Inve^iff(Uiam, 1906. 31 

of this growth was emulsified in 10 c.c. of sterile saline solution, and 
the four goats were inoculated subcutaneously at the root of the left ear 
witfi 1, 0*1, 0*01, and O'OOl c.c. respectively of the emulsion. Portions 
ol the remainder of the emulsion, after suitable dilution, were plated 
out and incubated. Enumeration of the resulting colonies showed that 
the emtdsion contained 10,000,000 cocci per cubic centimetre. 

Consequent upon these injections all four goats became infected : the 
blood serum from the first and second yielding a positive agglutination 
reaction with 1 in 10 and 1 in 20 dilutions on the seventh day. Serum 
from the third did not give a positive reaction until the seventeenth day 
in these dilutions, whilst the fourth, although giving a positive reaction 
in 1 in 10 dilution, gave an incomplete reaction only with 1 in 20 on 
the seventeenth day, and not until the thirtieth day did the serum react 
well with 1 in 20 dilution. 

From the clinical point of view there is little to record in connection 
with these inoculated goats. At no time during the course of the 
experiment did either of the goats appear to be ill — their coats were in 
good condition, no glandular enlargement was to be observed on palpa- 
tion, and the animals fed well, as usual. The temperature was somewhat 
irregular, but in this respect none differed markedly from the healthy 
animals that served as controls, as will be seen from the temperature 
charts {vide p. 32) of the four experimental animals and the one of 
the normal animals in an adjoining stable that showed the least exten- 
sive excursions from the normal line (which for the goat averages, 
according to Damant,* 103*5 — 104** F.), and so served as a control. 

All the animals were killed at the end of six weeks, and at the 
post-mortem inspection ample evidence of M, melUensis infection was 
available in the recovery of the organism from the spleen in all four 
goats, and in three of them from other organs as well. Details of this 
experiment are shown in tabular form (see Table VIII). 

A point of some interest may be noted in this experiment with 
regard to the relationship of the size of the dose of infective material 
to the date of onset of signs of infection. Thus the two first goats, 
which received 10 and 1 million cocci respectively, gave evidence of 
reaction to the infection, by the appearance of specific agglutinins in 
the blood, within a week of inoculation and a full 10 days earlier than 
the other two goats which had each received less than a million cocci. 

Cutcmeous Infection, — The suspicion that had been aroused with 
reference to the probability of infection being carried from goat to goat 
by way of the goatherd's hands when soUed with infective milk was 
strengthened by the knowledge that such a comparatively small amoimt 
of infective material injected subcutaneously was sufficient to produce 
infection. 

The technique adopted by the Maltese milker closely resembles 

• * Joxirn. Physiol./ Cambridge, 86, 1906 (Proceedings, v). 



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32 Dr. Eyre, Major McNaught, Capt. Kennedy, and Dr. Zammit. 



Chart No. 1. 



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Chart No. 5. 



Sahoutaneous Infection of the GK)at. 



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Bacteriological and IlxperimerUai Investigations, 1906. 33 

Aat of bis English confrere, and consists in lubricating bis own bands 
and the outside of tbe udder witb some of tbe foremilk. Wben a 
number of goats bave to be milked in rapid succession, the lubricant 
obtained from the first goat will serve for perhaps some half-dozen 
goats ; with the seventh goat a fresh supply of milk is taken for the 
same purpose, and so on. Now, given that Goat No. 1 or (Joat No. 7 
is passing M. melitensis in its milk, it is obvious that, at any rate, Gk)at 
No. 2 or No. 8, as tbe case may be, stands a very good chance of 
becoming infected by a process of subcutaneous inoculation; conse- 
quently steps were taken to investigate the possibility of this occurrence. 

In carrying out this expenment, the procedure of the goatherd was 
imitated as closely as possible, and Ooat No. 25/6, a healthy female, 
nearly full grown, was selected for the purpose of the experiment, cast 
on an operating table and securely held by assistants. A fairly large 
area of skin over the left mammary gland was shaved somewhat roughly, 
in such a manner as to remove in many places the superficial layer of 
epithelium as well as the hair, but care was taken to avoid drawing 
blood. Thus the shaved area replaced the scratches, abrasions, and 
small ulcers that are so frequently seen in the udder and teats of the 
milch goat. 

Next, the hands of the operator being protected by a pair of steri- 
lised indiarubber gloves, four drops of freshly-drawn milk from Goat 
No. 117 (amounting in total bulk to 0*2 c.c.) were delivered into the 
palm of the right hand from a sterile capillary pipette, and then 
thoroughly rubbed into the shaved area with movements similar to 
those practised by the goatherd as a preliminary to milking. The 
quantity of milk used was so small that the skin surface rapidly dried, 
and the goat was then isolated in a stall apart from the other animals. 
Immediately after the experiment was concluded, a sample of the milk 
that had been used was carefully plated out (after suitable dilution) and 
found to contain 24,800 M. melitensis per cubic centimetre ; the approxi- 
mate number of cocci, therefore, that came into contact with the prepared 
area of skin amounted to 5,600. 

Samples of blood were taken from a vein in the ear of this animal 
and examined from day to day for the presence of specific agglutinins, 
which first made their appearance on the fifteenth day (dilutions 1 in 10 
and 1 in 20). 

Three weeks after inoculation the goat was killed and a careful 
post-mortem examination carried out, with the result that the specific 
organism was recovered from the spleen and inguinal glands. 

At the same time Goat No. 23/6, a four-month-old female kid which 
appeared quite healthy, was selected as a control. The skin over the 
mammary gland was carefully examined with a hand lens, and an area 
quite free from scratches, cracks, or fissures was isolated by painting 
flexile collodion on the surrounding skin. Eight drops of milk from 
(13984) d 

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Bacteriological and Experimental Invedigations, 1906. 35 

Goat Na 117 was then depoeited on the centre of the prepared area 
and rubbed into the skin with the top of the forefinger — still protected 
by the rubber gloves. When dry, the kid was released, isolated in a 
separate stall, and subsequently specimens of blood were examined 
from time to time with negative results until the eighteenth day after 
inoculation, when the kid, which had been refusing its food for nearly 
a week, died. 

According to the animal attendants, death was due to the fact that 
an inferior batch of fodder, on which it had been feeding, was an 
unsuitable food for so young a goat. Be this as it may, at the post* 
mortem examination, beyond absence of fat and emaciation, no obvious 
cause for death could be detected. M, melitejim could not be found 
in any of the organs nor in the subcutaneous tissue or skin at the 
seat of inoculation, and specific agglutinins were absent from the blood 
serum. 

The successful result attending the cutaneous method of inoculation 
in the case of Goat No. 25/6 — a method closely resembling that 
employed in Jennerian vaccination — renders it extremely probable that 
convection by the flies which positively swarm in the goat pens, may 
play a part in the transmission of the infection from goat to goat. 
First settling on drops of infective milk or urine, soiling body and legs, 
as well as proboscis, and then flying to a scratch or friction ulcer on a 
previously healthy goat, whether on udder or other part of the body, 
it would be a very easy matter for the fly to deposit a sufficient number 
of if. melitenm on the raw surface to ensure infection. 

The result of the foregoing experiments, together with some 
observations made in connection with inoculation through the 
apparently uninjured mucous membrane of the external genitals of 
the monkey {vide p. 113), render the probability of infection of the 
goat during impregnation extremely likely — a probability which, so 
far as the male is concerned, is rendered still more likely owing to the 
fact that the female urethra opens into the floor of the vagina a couple 
of centimetres or more within the orifice of the canal, so that when the 
animal is passing M, mditensis in the urinary excretion the coccus must 
be present near the mouth of the vagina in considerable numbers. 
Unfortunately it was not feasible to test this method of infection 
experimentally, for, although numerous healthy and infected males 
were forthcoming, the late season rendered efforts to secure healthy 
and infected females in suitable condition for such experiment fruitless. 
Transmission of the coccus by means of blood-sucking flies, other 
than by mechanical conveyance upon body or limbs, for example, by 
Stomoxys calcUrans — which abounds in the goat stalls — appeared from 
the experiments carried out during the summer to be extremely 
improbable. The negative results obtained in this connection are 
detailed later (see p. 99). 

(13984) d 2 



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36 Dr. Eyre, Major McNaught, Capt. Kennedy, and Dr. Zammit. 

6. The Localisation of M. melitensis vn the Infected Chat. 
Inoculation of the goat with M, melitensis produces what must be 
regarded as an acute, or more commonly a sub-acute, septicemia — the 
specific organism living and multiplying in the circulating blood for 
a variable, often a considerable period — which but rarely proceeds to a 
fatal termination. 

Except on rare occasions when for the few .days immediately 
following inoculation the temperature is raised, the constitutional 
disturbance accompanying infection is but little marked, and soon 
ceases to be demonstrable; later on the presence of the specific 
organism can be detected in excretions and secretions, viz., the urine 
or milk, or both; but these phenomena are by no means constant. 
Observations were therefore undertaken as opportunity offered with 
a view to tracing the route followed by M, melitensis in the course of 
the disease as observed in goats, by studying the post-mortem 
localisation in cases of different durations in the light of the 
information derived from similar observations on the course of the 
disease in the monkey. 

The results obtained, however, are extremely conflicting {vide Table X), 
and the general statement to be formulated immediately, although 
probably true in the great majority of goat infections, can only be 
accepted at the present stage of the investigations as a pious opinion 
or a working hypothesis. 

During the early stages of the infection the blood stream and the 
spleen are the chief seats of M. melitensis activity : later the coccus 
becomes localised to the speen, lymphatic and other glandular 
structures and kidneys, probably by the operation of a process akin to 
filtration, but during its existence in the spleen the possibility of its 
re-appearance in the blood is ever present. Later still those foci 
present in the kidneys are destroyed, next those in the spleen, then 
those in the general lymphatic glandular system, so that in infections 
of long duration the coccus may be absent from all and every organ 
with the exception of the mammary gland, where it may persist for 
very extended periods. 

In addition to tabulating the observations upon ^hich the opinions 
enunciated above are based, it will be well to discuss in order the chief 
organs and tissues from which 3f. melitensis has been isolated. 

1. The 'Blood, — Zammit, working with naturally infected goats, noted 
that ** in certain phases of the disease the specific microbe circulated 
freely in the blood, but that this condition did not last long."* Again, 
Eyre, whilst using living cultures in the attempt to immunise the 
goat and the horse, found that living cocci could be isolated from the 
peripheral blood for about four weeks after an injection.! 

• rWe these Reporte, IV, p. 97. 
t Beporto, Y, pp. 45 and 49. 



Digitized by VjOOQ IC 



Baderidogiccd arid Experimental Investigations^ 1906. 37 

During the period of incubation, that is to say, between the moment 
of actual infection and the rapid multiplication of the coccus in the 
circulating blood, usually some 7 to 21 days, attempts to isolate the 
coccus from peripheral blood are invariably unsuccessful. 

Beferring once more to the immunising experiments, it was 
obeerved that during the first fortnight after the intravenous 
injection of living cultures of M. melitensis it was a comparatively 
easy matter to isolate the coccus from peripheral blood, although in 
gTEidually decreasing numbers, by simple cultivation methods ; by the 
third week the numbers present were small, and after the fourth week 
it was not possible to detect the presence of the micrococcus either by 
cultivation or inoculation experiments. 

Then, too, in none of the animals tabulated below was the specific 
coccus isolated from the heart blood, although one was examined 
post mortem three weeks after infection. 

Zammit, however, remarked that some of the goats from whose 
blood he isolated the micrococcus were undoubtedly cases of long 
standing, a statement based on a consideration of the physical 
condition of the goats to which he refers ; and the fact that two of 
them were in poor condition and were passing M, melitensis in the 
milk, lends support to the inference. While it is true that these cases 
might really have been recent infections, the physical condition and 
presence of the coccus in the milk being due to the exceptional severity 
of the infection, this is hardly likely ; and the more probable explanation 
is that in cases of long duration, temporary re-infection of the blood 
stream sometimes occurs from foci in the spleen — a condition 
analagous to that observed in man during the course of protracted 
cases of Malta Fever. 

In the majority of cases, therefore, the ready isolation of the coccus 
from the peripheral blood by cultivation methods would afford strong 
support to a diagnosis of recent infecnon. 

Spleen, — As will be seen from the synopsis of post-mortem findings 
in Table X, it is quite the rule to isolate the micrococcus from the 
spleen in cases of short duration and up to about 1 2 months after 
infection, at any rate where the infection has been experimentally 
produced. In animals where the infection has existed for a considerable 
period (many of the post-mortems being carried out on animals which 
were naturally infected when purchased and had been imder 
observation for periods extending over 12 to 20 months) it is the 
exception rather than the rule. 

Lymphatic Glandular System, — There is as a rule in cases of long 
duration, as well as the more recent ones, a general enlargement of the 
lymphatic glands, from all of which the M. melitensis can be isolated. 
In recent infections those glands draining the location of the primary 
infection contain numerically more of the cocci than those which have 

Digitized by VjOOQ IC 



38 Br. Eyre, Major McNaught, Capt. Kennedy, and Dr. Zanuuit 



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Sacteriologieal arid Experimented Investigations, 1906. 39 



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40 Dr. Eyre, Major McNaught, Capt. Kennedy, and Dr. Zammit. 

merely derived their bacterial content from the circulating blood, and 
in the very early stages {vide Goat No. 25) the former glands may alone 
contain the coccus in demonstrable quantities. 

Towards the termination of the infection the lymphatic glands — 
particularly the inguinal — appear to be the last resting place of the 
coccus before its final destruction, and in a previous report* this fact 
has been commented upon by various workers who have expressed the 
opinion that had the examination of the superficial lymphatic glands 
in the case of many infections of long standing been neglected, posir- 
Hve evidence of infection by the isolation and identification of the 
M, melUensis would have been entirely missed. On the other hand, the 
evidence available by no means justifies the opinion, also there expressed^, 
that the lymphatic glands were the site of especial reproductive 
activity on the part of M, melUensis. That the glandular infection 
is not limited to those glands draining the area first infected is well 
shown in the post-mortem results of inoculated monkeys {vide pp. 34, 51, 
and 114) which were examined in the early stages of the disease. In 
the cases, for instance, of food infection, inguinal and axillary glands aa 
frequently yielded a copious growth of M, melUensis as the mesenteric 
(or bronchial and cervical, although these last are not included in the 
tables); and in the case of a cutaneous infection (Monkey No. 188) a^ 
well as in those of mucous membrane infection (Monkeys No. 200 and 
203) when the mesenteric glands gave a growth equal to that from any 
of the subcutaneous glands. 

Kidney. — Although the presence of M. melUensis in the tissues of 
the kidney practically synchronises with the appearance of numerous, 
cocci in the blood stream, the extrusion of the micro-organism in the 
urine is in the majority of the experimental animals a somewhat late 
phenomenon. In man, on the other hand, the coccus may be demon- 
strable in the urine quite early in the acute stages of an attack of 
Malta Fever. In the rabbit and guinea pig its appearance — although 
usually late — is fairly constant ; in the goat, however, the elimination 
of the coccus is by no means constant even in cases of very long 
standing, and it is of interest to record the fact that frequently 
repeated examinations were made of the urine from all of the infected 
milch goats, some 20 in number, under observation at the Lazzaretto 
over a period of about a couple of months without the presence of the 
coccus ever being detected — although 18 of the animals were 
eliminating large numbers of the coccus almost daily in the milk. 
Again, the discharge of the coccus in the urine in cases where it has 
be^n observed appears to cease long before its disappearance from 
the milk. 

Mammary Glamd. — In the few post-mortem observations that were 
made as to the presence of M. melUensis in this situation, it may be 
• Ffde these Beport*, IV, p. 69. 



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Bacteriological and Escperimental Investigations, 1906. 41 

noted that the organism was detected distributed throughout the 
substance of the gland in the case of a goat that had previously 
yielded the coccus in its milk but had been " dry " for some weeks 
before it was killed. In three other cases small pieces of the base of 
the udder, containing the deepest portions of the glandular tissue, were 
removed. In one (where the coccus had appeared in the milk after 
die lapse of seven weeks from the date of infection) killed eight 
months after infection, the coccus could not be recovered from the 
mammary gland or any other of the organs examined. In another 
which had never shown M, mditensis in the milk during life^ 
and which was killed ten months after experimental infection, the 
micrococcus was absent from all organs and tissues. In the third, 
killed 12 months after experimental infection, the coccus was isolated 
from the mammary gland alone of all the tissues examined. 

Where the milk has been systematically examined in animals that 
have been experimentally infected, the appearance of the coccus in the 
milk has invariably been a late phenomenon. Goat No. 4, for 
example, commenced to eliminate the coccus seven weeks after 
infection. Goat No. 8 three months. Goat No. 7, on the other hand, 
was infected in September, 1 904, and, although repeatedly examined, 
showed no signs of the coccus in the milk up to January, 1906, when, 
being "dry," she was impregnated. In July, 1906, she dropped two 
kids, and three days later the coccus appeared in the milk and was 
consistently present up to 24th September, when she was slaughtered, 
and it is interesting to note that in this case the coccus could not be 
recovered postmortem from either spleen, kidneys, or lymphatic glands. 

7. The Transmission of M. melitensis Antirbodies to the Descendants 
of Infected Goats, 

A further interesting point, and one which has a considerable 
bearing upon practical preventive measures against the spread of 
M. mditensis infection in the goat, is the fact that while an appreciable 
amount of specific agglutinin is usually transferred from the infected 
milch goat to its offspring, the M, melitensis itself, minute though it 
is, does not appear to cross the placenta.* These observations were 
repeated on several occasions as opportunity offered, and the details 
concerning four kids born of experimentally-infected mothers (all 

• One obserration upon the human subject where transference of the micro- 
coccnt from the maternal to the foetal circulation appears to have taken place 
in utero may here l>e referred to. A pregnant woman (uDder the care of Captain 
Williams, BA.M.O., in the Married Families Hospital, Valletta) gave birth to 
a male infant during one of the pjrexial periods of an acute attack of Mediterranean 
Fewer. The infant proved to be infected also, the agglutination value of its serum 
was 1 in 1000 — as compared with its mother's 1 in 600— and its temperature curve 
from birth followed precisely that of the mother, although about half a degree 
lower, during the subsequent fluctnatioDs. 



Digitized by VjOOQ IC 



42 Dr. Eyre, Major McNaught, Capt. Kennedy, and Dr. Zammit. 

of which were passing if. mdUensis in either milk or urine, or both, 
up to the time of impregnation, and even after), may be tabulated as 
follows : — 



Milch goat. 


Kid8 born. 


Serum Talue 
in kid. 


Kid kiUed. 


PotUmoHem retults 
qua M, melUentit, 


1 
2 

8 


26.10.06 
2.8.06 

14.7.06 1 


1: 60 
1: 800 
a 1: 60 
b 1:20 


18.11.06 

4.3.06 

31.7.06 

31.7.06 


1 

Nil. 
Nil. 
Nil. 
Nil. 



Even the small amount of agglutinin present in the serum of the 
kids of infected goats appeared to be associated with a very definite 
immunity, for the two Mds of (Joat No. 3 were fed for 17 days 
on their mother's milk, and for the last 10 days of this period the 
milk was teeming with M. mdUensiSy yet, at the post-mortem inspection, 
no trace of M, melUensis infection could be detected. 

On the other hand, two kids which had been dropped, and subse- 
quently reared by a similarly infected mother, were injected 
subcutaneously, when they were seven weeks old, with emulsion of 
cultivation of M, melitensisy and were quite unable to resist infection, 
showing that the resistance offered to invasion by M. vielitensis can 
readily be overcome. 

8. The TrecUmeni of Infected Milch Goals tvith the M. melitensis Vaccine, 

The lengthy periods over which apparently healthy milch goats con- 
tinue to secrete milk of a highly infective character rendered it desirable 
to inquire into the utility of therapeutic measures in determining the 
duration of active infection. To this end observations were com- 
menced with regard to the effect of treatment by M. melitensis vaccine, 
as it appeared useless to try any of those drugs that had already proved 
useless in the treatment of M. melitensis infection in the human 
subject. 

Consequently, early in August a batch of vaccine was prepared from 
a highly virulent strain of M, melitensis in the manner described in 
Section VII, p. 116, and standardised to 1000 million micrococci per 
cubic centimetre. Seven of the hei-d of infected milch goats and 
sheep stabled in the Lazzaretto were selected for the purpose of the 
experiment — four for treatment, Nos. 104, 111, 114, and 117; and 
three — 105, 107 (sheep), 116 — ^to serve as controls ; the milk from all 
of these animals usually contained M, melitensis — often in enormous 
numbers — as will be seen by reference to Table VII, p. 20. Unfor- 
tunately, Gk»ats Nos. 105 and 111 ''dried up" shortly after the 
experiment was started. 



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Bcusterwlogical ani Experimental Investigational 1906. 43 

The bi- or tii-weekly enumeration of the cocci present in the milk 
of these seven animals was continued, and observations on the agglu- 
tination reaction in serum and milk were also carried out. 

Table XL — M. mditensis in Milk of Vaccinated Goats and Controls. 











Controls. 


Animal 
and Ko. 


Goat 104. 


r^ - - . 


/^ - . j_ tttm 






Groat 114. sxwkn 1.1.1. 














Gk)atll5. 


Sheep 107. 


Ang. 2 ... 


16,000 


80,000 


24,800 





1,810 


„ 4 ... 


— 


80,000 


— 


780 


— 


,. 7 ... 


660 


— 


— 


— 


1,000 


„ 8 ... 


Injected with yaooine 
(500,000,000 oooci) 






„ 9 ... 


1,250 


8,300 ; 1,200 


8,m)o 


300 


„ 11 ... 


50 


3,000 


16,000 


8,500 


2.500 


„ 14 ... 


1,600 


nU 


80,000 


8,000 


20,000 


„ 17 ... 


1,500 


— 


3,400 


— 


4,200 


„ 18 ... 


750 


6,000 


— 


— 


720 


„ 21 ... 


1,400 


200 


2,000 


— 


1,500 


„ 21 ... 


Injected with vaccine 
(1,000,000,000 cocci) 


""■ 


■"" 


„ 23 ... 


700 


5,000 


200 


1,020 


20.000 


„ 25 ... 


2,000 


— . 


30,000 


3,200 


30,000 


Sept 4 ... 


— 


88 


525 


nil 


700 


,, 6 ... 


110 


— 


1,161 


360 


1,600 


„ 8*... 


176 


— 


471 


60 


2,280 


„ 11 ... 


127 


300 


200 


660 


2,245 


„ 15 ... 


189 


800 


• 


1,200 


3,456 


„ 15 ... 


Injected with vaccine 
(1,000,000,000 cocci) 


— 


^~ 


„ 18 ... 


185 


• 207 1 


350 


4,300 


„ 20 ... 


• 


nU 


320 


560 


5,280 


» 22 ... 


nU 


• 


170 


150 


• 


„ 26 ... 


10 


20 


360 


100 


• 


„ 27 ... 


65 


15 


230 


50 


5,300 



* Plates so contaminated as to be nnworkable. 

The initial dose of vaccine was 0*5 c.c, equivalent to 600,000,000 
cocci, which was injected subcutaneously in the animars flank. In the 
course of 12 hours or so the small local swelling caused by the injection 
had completely disappeared, the animal seemed to be in no way dis- 
commoded by the injection, and no marked rise of temperature took 
place. Within two or three days the agglutination ^ue of both 
serum and milk fell in a most pronounced fashion, and on one occasion, 
in the case of (^oat No. 114, disappeared altogether from the milk. Four 
or five days later the dilution in which the agglutination reaction 
could be obtained had again risen to a higher level than it had occupied 
previous to the injection of the vaccine — ^in short, the phenomena 
observed were exactly comparable to those noted in rabbits and guinea- 



Digitized by VjOOQ IC 



44 Dr. Eyre, Major McNaught, Capt. Kennedy, and Dr. Zammit. 

pigs under similar conditions.* The numerical strength of M. meliiensis 
in the milk at first appeared to be as irregular and as erratic as before 
the treatment was commenced, but after a second injection of a some- 
what larger dose of vaccine (1 c.c, or 1,000,000,000 cocci) 14 days 
after the first, the numbers underwent a certain diminution. Unfor^ 
tunately, about this time the milk of another of the controls commenced 
to dry up, and within a month of the commencement of the experiment 
only small quantities of milky fluid could be obtained from this animal 
for examination. The Sheep No. 107, however, continued to yield a 
good supply of milk containing M, meliiensis in undiminished numbers. 
These observations are being continued, for it is obvious that any 
method of treatment which would cause the destruction of the micro- 
coccus in the infected goats and its disappearance from the milk would 
be a most valuable weapon in the hands of those who desire to stamp 
out Malta Fever from our Fleet and garrisons. 

In the accompanying table (p. 43), which gives the nimiber of cocci 
per cubic centimetre in the milk of the treated goats and in the controls, 
the diminution in the former may be readily followed. 

II. — J/, meliiensis INFECTION BY EXPERIMENTAL Feeding with 
Infective Goats* Milk. 

1. General Considerations, . 

The experimental work undertaken by the Commission during the 
years 1904 and 1905 proved beyond question the possibility of pro- 
ducing a generalised infection in monkeys, goats, and kids as the result 
of feeding them upon articles of diet artificially contaminated with 
M, meliiensis, although many of the earlier experiments were negative, 
and the value of some of the later positive experiments is depreciated 
owing to their lengthy duration, which affords opportunity for the 
introduction of numerous fallacies. For convenience of reference and 
comparison, these early experiments in the monkey dealing with infection 
viA the alimentary system, have been tabulated (see pp. 46 and 47). 

The method of experimentation that was adopted (t.«., the repeated 
administration of contaminated food on successive or alternate days, 
often for long periods of time), combined with the difficulty of demon- 
strating the presence of M, meliiensis on every occasion that supposedly 
contaminated articles of diet were administered, left many points of 
interest for further investigation. 

Perhaps the most important of these was the question whether the 
administration of one quantum of contaminated food was sufficient to 
produce an M, meliiensis infection vid the alimentary tract, for, if so, 
the equally important question of the duration of the incubation 
period of the disease would necessarily be further elucidated. . 
• Vide these EeporU, V, p. 44. 



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Bacteriological and Experimental Investigations, 1906. 45 

From the experiments tabulated below, it would at first sight be 
assumed that enormous doses of the virus are required to produce 
infection, and that the period of incubation, though varjdng within very 
wide limits — from 14 to 76 days — was usually a lengthy one; but a 
careful consideration of the various factors involved in those experi- 
ments is sufficient to show that such an assiunption might well be 
fallacious, for the simple reason that the appearance of specific 
agglutinins in the blood serum was the criterion adopted as the 
evidence of infection. Now, it has already been shown elsewhere 
in these Beports {vide Part Y, p. 45) that an animal inoculated with an 
excessively large dose of the micro-organism, or repeatedly injected 
with dead or with living cultures of M, inelUensis, either fails altogether 
to elaborate specific agglutinins, or if such are present at the com- 
mencement of the experiment, fails to elaborate fresh supplies, whilst 
that previo'usly stored in the serum is rapidly destroyed. An obvious 
explanation of the very lengthy incubation periods would therefore be 
that many of the animals to which repeated doses of M, melUensis were 
administered in the shape of daily supplies of food infected with the 
microorganism, failed to form the specific agglutinins either until very 
late in the course of the infection, or until the temporary cessation of 
the " feeding," or the accidental absence of M. melUensis from the pre- 
sumably infected food afforded the necessary respite, and allowed the 
response to the presence of the micro-organism to emerge from the 
negative into the positive phase. Again, the experimental inoculation 
of laboratory animals {e,g,y guinea-pigs, and particularly white rats) 
has shown that death frequently takes place when even a 1 in 10 agglu- 
tination reaction is absent and has been absent throughout the course 
of the infection, while the post-mortem examination reveals the fact 
that all the organs are teeming with the M. melUensis. 

In support of this view, the case of Monkey No. 2 may be quoted 
(see Table XII). This animal was — with the exception of one day — fed 
continuously for 74 days with infective milk, and during this period 
no agglutination reaction could be obtained with the blood serum. The 
day following the cessation of the feeding, a very doubtful 1 in 10 
reaction was obtained ; nine days later the animal suddenly died, and 
at the post-mortem examination M, melitensis was recovered from spleen 
and from glands, although the blood serum still yielded merely an 
incomplete reaction with a 1 in 10 dilution. 

These facts make it a matter of regret that the supply of animals 
for the early experiments was insufficient to allow of any considerable 
number being utilised for each experiment Had it been possible tp 
include more animals in certain of the experiments, so that some might 
have been killed and exBomned post-mortem during the course of the 
feeding, it would probably have been found quite frequently that 
infection had taken place at a very much earlier stage than was 
indicated by the appearance of the serum reaction. 

Digitized by VjOOQ IC 



46 Dr. Eyre, Major McNaught, Capt. Kennedy, and Dr. Zammit. 



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Ba^ieriological and ExperimerUal Investigations, 1906. 47 



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48 Dr. Eyre, Major MoNaught, Capt. Kennedy, and Dr. Zammit. 

Basing a working hypothesis upon these considerations, and planning 
the experiments so that the results might yield the maximum of infor- 
mation, a considerable number of feeding experiments were performed, 
which for convenience of study are divided into six series. The main 
object of the experiments was to obtain exact information of the effects, 
if any, produced by the ingestion of a limited quantity of infective 
material ; therefore it was determined to administer to each animal but 
one quantum of infected food, then, after a few days' interval, to com- 
mence testing the blood for the presence of agglutinins, and thence- 
forth to continue to apply this test on alternate dajrs ; and from the 
third week onwards to kill and examine post-mortem one or more 
animals each week. These experiments may now be described as 
follows : — 



2. Feeding with Naturally Infected Milk Artificially Reinforced, 

Series L — Eight monkeys {Macacus rhesus) were employed in this 
experiment. 

From the time of their arrival from Calcutta these animals were 
kept under observation at the Lazzaretto as to temperature and general 
condition, and were fed on soft food — boiled rice and boiled potato, 
together with sugar and water, and the blood serum from each 
repeatedly examined for M. melitensis agglutinins. The general 
condition being satisfactory, no lesions of the mucous membrane of the 
mouth, or of the skin of the face, hands, or feet being apparent to 
visual inspection, and specific agglutinins being absent from the blood, 
the monkeys were brought over to the laboratory at Valletta and 
arranged on the roof terraces. Each monkey was fastened in close 
proximity to a separate wooden cage by means of a chain, rather more 
than a metre in length, fastened at one end to a staple in the wall, and 
at the other to a ring in a leathern dog-collar secured around the 
animal's neck. Each monkey was separated from his neighbour on 
either side by a wooden pailition, some 6 feet in height, projecting at 
right angles from the wall on which the cage was fastened for about 
6 feet, and set in cement at its junction with both wall and pavement. 
By this means not only was personal contact between a monkey and 
its neighbour or neighbours rendered impossible, but the chance of 
contact with food or excrement other than its own was also obviated. 
In addition to the soft food previously mentioned, each monkey was 
supplied with about 250 cc. of sterilised goats' milk per diem for 
three days. This they readily learned to lap up as they did water. 
On the fourth day they had the usual morning feed, together with 
sterilised milk at S a.m., but no more food was given that day. The 
following morning. May 13, 1906, the administration of infected 
food — goats' milk — took place. The infected milk employed in this 



Digitized by VjOOQ IC 



Bacteriological and Expeni)ieivtal Lwestiffaiiojis, 1906. 49 

experiment was " mixed milk " derived from a herd of nine goats just 
received at theLazzaretto from Babato, five of which were known to be 
excreting if. melitensis in varjdng numbers in their milk, while the 
remainder were suspeqted of doing so on account of the agglutination 
reaction yielded by the milk, and the fact that if. melitensis had been 
isolated from the milk before they passed into the Commission's posses- 
sion, although the micro-organism had not been recovered from the milk 
during their stay in the Lazzaretto up to the date of the experiment. 

Having regard to the fact that any given milch goat shows great 
variations in the number of M, melitensis excreted in the milk even from 
day to day, a single agar slope culture of M. melitensis derived from the 
milk of Goat No. 104 was emulsified in sterile saline solution, and added 
to the two gallons of milk obtained from the infected herd. Plate 
cultivations were then prepared from the milk itself, and from various 
dilutions thereof, and after incubation at 37** G. for four days the 
colonies of M. tmlitensis which had developed were enumerated, and 
it was finally estimated that each cubic centimetre of the infected milk 
when supplied to the experimental monkeys contained 11,000,000,000 
M. melitensis. That is to say, on this occasion, the milk contained 
.If. melitensis to the niunber of about 10,000,000,000 per cubic cen- 
timetre before the laboratory culture was added. 

The method of administration of the infective material was quite 
simple. As the monkeys were accustomed to receive sterilised milk as 
a regular article of the daily dietary, a small amount, 250 c.c, was 
supplied to each monkey in a clean pattnikin at 9 a.m. From the 
laboratory window the animals were iiatched, and it was seen that 
each lapped up a certain quantity of the milk, in most cases small in 
amount, or, lifting up the pannikin, drank from it as one would from 
a cup before turning the receptacle upside down to ascertain whether 
other more solid food was concealed beneath. At 11.30 a.m. the 
pannikins were cleaned and a further 250 c.c. supplied to each animal, 
when the same performance was gone through. Each animal, in all 
probability, consumed 30 c.c. to 50 c.c. of the milk; certainly no animal 
ingested as much as 100 c.c. At 2 p.m. the usual feed of boiled rice 
was given, and from that time forward the- ordinary meals were 
supplied and no more infected material was administered. 

To serve as controls two healthy monkeys were each supplied with 
sterilised goats' milk in similar quantities, and as the two following series 
were carried out on the same day, they acted as controls for those also. 

Six days after the administration of the infected milk a specimen of 
blood was taken from each monkey and tested for the presence of 
Af. melitensis agglutinins. The result in each case was negative. This 
testing for the serum reaction was repeated thenceforth three or four 
times every week until the termination of the experiment. On the 
10th day after feeding the first agglutination reaction was observed 
(13984) e 



Digitized by VjOOQ IC 



50 Dr. Eyre, Major McNaught, Capt. Kennedy, and Dr. Zammit. 

(1 : 10); on the 12th day three other monkeys gave a good serum 
reaction in low dilutions (1 : 10, 1 : 20, and 1 : 20), while the first 
animal gave only an incomplete reaction in 1 : 10. On the 15th day 
three more monkeys reacted 1:10, 1 : 10, and 1 : 80 respectively, and 
on the 20th day the eighth monkey of the series yielded a 1 : 10 
reaction. On this day also Monkeys Nos. 160 and 161 were chloro- 
formed and autopsies performed, and in these, as in all post-mortems 
conducted in the laboratory, a thorough examination was carried out. 
In addition to the usual naked eye inspection, plate and tube cultiva- 
tions were invariably established from the spleen, the axillary and 
inguinal glands, and at least four mesenteric glands; 10 cubic 
millimetres of blood taken directly from the heart were plated out, 
and a further supply of blood was collected for the purpose of deter- 
mining the agglutinating value of the serum at the time of death. . 

Naked eye inspection of Monkeys Nos. 160 and 161 showed noUiing 
beyond general glandular enlargement, and hypertrophy of the spleen, 
which was of a dark colour, hard and friable ; but as the result of the 
bacterioscopic examination both these animals were found to harbour 
ilf. melitensis in the blood »nd in every organ examined. 

Eight days later, that is four weeks from the day of feeding, one of 
the control monkeys was killed by chloroform and examined, but 
the result of the autopsy was completely negative. All the organs 
appeared normal, the blood serum possessed no agglutinating power 
whatever when tested against M, melUenm ; nor could 3f. melitensis be 
demonstrated in any of the:» organs or tissues examined culturally. 
The second control was killed on the 36th day, and jdelded identical 
results. Two more animals of this series were killed and autopsies 
performed on the 32nd day after feeding, the M, melitensis being- 
rec^overed from one or more organs in each case, the spleen invariably 
yielding a growth of the micro-organism. 

The full details of this experiment are tabulated below, while th& 
net result may be summarised by saying that of eight experimental 
monkeys fed once on somewhat grossly infected milk, eight became 
infected by M. melitensis (as proved by results of post-mortem examina- 
tion) after an incubation period varying from 10 to 20 days (a» 
indicated by the date of appearance of the serum reaction). 

Series 11. — To contrast with the first series of animals, a further 
batch of similarly selected monkeys (from the same Indian consign- 
ment) were simultaneously prepared for feeding. In substitution for 
the rice and potatoes in the diet supplied to the animals in Series I,. 
the monkeys in Series II received for the corresponding three days- 
medlars, small Spanish nuts which they cracked between their teeth 
in order to get at the kernels, and hard roasted peas, the object being^ 
to afford the animals every opportmiity of abrading the mucous 
membrane of the buccal cavity, and so facilitating the entrance of 



Digitized by VjOOQ IC 



Bacteriological and Experimental Investiffatiom, 1906. 51 



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52 Dr. Eyre, Major McNaught, Capt. Kennedy, and Dr. Zamniit. 

M. melitensis — converting, in fact, the feeding experiment into a 
subcutaneous inoculation, and imitating that condition of the mouth 
which must be frequently present in human subjects resident within 
the endemic area of Mediterranean Fever — in the anticipation that 
earlier infection associated with severer constitutional symptoms would 
sufficiently indicate that the desired end had been attained. Anxiety 
to ensure the ingestion of the infected food appears, however, to have 
caused the failure of this portion of the experiment, for the monkeys 
in Series II received their last lot of nuts and peas on the morning 
of May 12, and, like the animals in Series I, received no more food 
until the infected milk was placed before them 24 hours later, by 
which time any small abrasion caused by cracking nuts would, most 
probably, have been sealed off from contact with the contents of the 
mouth by a protective coating of serum. 

Of this batch the first monkey gave a serum reaction of 1 : 10 on the 
12th day after feeding with infected milk, four reacted for the first 
time on the 15th day and two more on the 20th day. One cubic 
centimetre of blood was abstracted from the external saphenous vein 
(by means of a small serum syringe) of Monkey No. 157 on the 
18th day after feeding, and planted into 20 c.c. of broth. After three 
days' incubation at 37 ** G. of this first broth reinforcement, plate 
cultures therefrom yielded a pure culture of M, melitensis. Six of the 
remaining monkeys were killed on the 21st, 32nd, 36th, and 37th days 
after feeding, and cultural examination of the various organs specified 
in connection with Series I yielded abundant evidence of generalised 
infection by M. melitensis. 

The eighth animal of Series II alone remains to be accounted for. 
This monkey gave a not quite complete reaction in a dilution of 
1 : 10 on the 10th day after feeding ; on the 35th day a similar 
reaction in 1 : 40 dilution. 

It was killed by chloroform vapour on June 25, when it gave 
similar, not absolutely complete, reactions in all dilutions up to 
1 : 40. At the autopsy general glandular enlargement of the axillary 
and inguinal glands was noted, associated with visible distention of the 
superficial lymphatics. The mesenteric glands were enlarged — some 
purulent, others caseous, and coverslip film preparations from both 
varieties, stained by the Ziehl-Neelsen method, showed the presence of 
acid-fast bacilli morphologically indistinguishable from B. tuberculosis. 
The spleen was large, dark, and friable, and studded all over with 
miliary tubercles ; the lungs, liver, and kidneys appeared normal — the 
whole making a typical picture of early generalised tuberculosis. 
Cultivations from heart's blood, spleen^ and the usual glands remained 
sterile up to the end of 10 days, when the period of observation of the 
cultivations was brought to a close. The most interesting point 
in this case was, of course, the pseudo-reaction that was obtained with 



Digitized by VjOOQ IC 



Bacteriological and E^'^yerinieiital Investigational 1906. 53 



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64 Dr. Eyre, Major McXaught, Capt. Kennedy, and Dr. Zammit. 

the blood serum even up to a dilution of 1 : 40, and at once suggests an 
explanation of some of the anomalous reactions that are obtained with 
M. meliiensis in cases of obscure fever in man. 

All the essential details of this experiment (Series II) are tabulated 
(p. 53), the net result being that of eight experimental animals, one, 
suffering from Tabes rnesenteiica, was not infected with M. mdH^msis, 
the remaining seven became infected after an incubation period 
varying from 12 to 20 days, but presented no especial features as to 
severity, constitutional symptoms, or of febrile reaction or early 
appearance of serum reaction that would indicate that infection had 
taken place by a different path to that traversed in Series I. 

This experiment, therefore, although successful in showing the 
possibility of infection by means of infected food, failed to differentiate 
between absorption through normal and injured mucous membrane. 

Series III. — In a further attempt to investigate the factors involved 
in the infection through the alimentary system, a third batch of eight 
monkeys selected for the purpose in a manner similar to that adopted 
in the two former series were injected subcutaneously, each with 1 c.c. 
of B. typhosus vaccine, a few hours after the morning meal on May 12, 
with the object of producing a marked constitutional disturbance 
which should not have passed off by the time the milk infected with 
M, melUensis was administered. 

This object was certainly attained — two of the animals in fact 
succumbed, one being dead on the following morning at 6 a.m., the 
second dying a few hours after the administration of the infected milk. 
The remaining six monkeys were clinically distinctly ill, although in no 
case did the temperature rise above 104° F., repeatedly drank small 
quantities of the infected milk and refused the rice supplied to them in 
the afternoon. The following day all were apparently well, and the 
local swelling marking the seat of injection of the vaccine disappeared 
completely in the course of a few days. 

The results obtained were somewhat conflicting. One animal showed 
a serum reaction (1 : 10) on the 15th day, and an incomplete reaction 
(1 : 10) on the 20th day. The agglutinins then disappeared from the 
blood, and could not again be demonstrated until the d3rd day, when 
the reaction was obtained in a dilution of 1 : 20. Two more animals 
reacted on the 20th day, while the sixth, which showed no signs of the 
presence of agglutinins in the blood, was killed and examined po$t' 
mortem on the 24th day, after feeding showed absolutely no evidence of 
M, meliiensis infection. In two only of the five animals that were 
infected was M. m^litensis generalised throughout the body. In the 
remaining three it was recovered with difficulty — ^from the spleen alone 
in two and from the spleen and mesenteric glands in the third. 

Despite the danger attending generalisations founded on insufficient 
premises, it would almost appear that the response of these animals to 



Digitized by VjOOQ IC 



Bacteriological and Experimental Livestigaiiom, 1906. 55 

the injection of B, typhoms vaccine had in some obscure maimer enabled 
the majority of them to make a better fight against the invading 
M. mdUenaiSy and to achieve a more rapid destruction of the organism, 
than any of their fellows who had not been so stimulated prior to the 
administration of the infected milk. The details of this experiment are 
given in the accompanying 'table (p. 56). 

As these three series of feeding experiments were carried out 
simultaneously and under similar conditions of environment, the same 
two controls served for all, and the details concerning them will be 
found tabulated with those of the experimental monkeys in each series. 

Having by these experiments shown that the ingestion of a small 
amount of somewhat heavily infected milk was sufficient to determine 
a if. melitensis infection after an incubation period varying from 10 to 
20 days, it now remained to ascertain whether naturally infected 
milk — without reinforcement by the addition of laboratory cultivation 
— would suffice to yield a like result, and to this end further sets of 
experiments were initiated. Before detailing these, however, some 
comment is necessary on the two possible sources of fallacy which may 
be urged against the foregoing experiments, viz. : — 

(A) Infection conveyed by means of mosquitoes and biting flies. 

(B) ** Place " infection — by reason of the fact that during the last 
two and a-half years each and all of the wooden cages had been 
inhabited at various times by infected monkeys, and were, therefore, 
possibly more or less contaminated with infective excrement. 

Dealing first with (A), it should be noted that during April,* May,t 
and the early part of June,! 1906, an exceptionally cold spell of 
weather prevailed throughout the island, a few Culex (of the common 
species, fatigans and pipiens) were observed and caught inside houses, 
but neither they nor Acartomyia or Stegomyia appeared in the 
Laboratory or on the terrace until long after many of the experimental 
animals had given unmistakable evidence of the infection. Flies 
also were conspicuous by their absence ; Stomoxys was not observed 
upon the terraces during these experiments, and it was not until well 
on in June that it could be obtained, even from stables, in quantities 
sufficient for experimental work. These points, however, are by them- 
selves insufficient to absolutely negative the objection raised under 
heading (A). 

In the succeeding experiments further precautions were taken for the 
express purpose of eliminating the possibility of infection through the 

• April, 1906, WM the oddest April in the five jean 1002^1006, with 26 days 
in defect of the a?erage for the five-year period. 

t Kay, 1906, was the coldest May in the five jears 1902—1906, with 20 days in 
defect of the average for the five-year period, 

t Jmie, 1906, was the coldest Jnne in the five years 1902—1906, with 20 days in 
defect of the average for the five-year period. 



Digitized by VjOOQ IC 



56 Dr. £}Te, Major McNaiight, Capt. Kennedy, and Dr. Zammit. 






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Bacteriological aiid Eiqyeriimiital Investigations, 1906. 5T 

agency of insects. The animals employed were selected from a 
consignment of monkeys that arrived in Malta from Calcutta early 
in July. On their arrival at the Lazzaretto they were placed in 
mosquito- and fly-proof rooms where they remained imtil their trans- 
ference to the Laboratory terraces. Here they were allotted sleeping, 
boxes, each of which was accommodated in a separate cubicle similar 
to those employed in the first three experiments, but rendered mosquito- 
and fly-proof by roofing with wood, fronting with a gauze covered 
framework with hanging door, and caulking all joints and cracks in the 
woodwork with putty, or pasting them over with stout paper. 

With reference to the possibility of infection having taken place 
through contact with the excrement-polluted woodwork of the 
sleeping boxes, it may be stated that before allotting a box to a 
normal monkey, it was first scraped clean^ then thoroughly scrubbed 
inside and out with a 2-per-cent. solution of Lysol, and the wood 
saturated with the same j then the box was dried in the sun. When 
thoroughly dry, it was again scrubbed with a fairly strong solution of 
caustic soda until the wood had regained its pristine whiteness, and no 
stain or discoloration was >asible, well rinsed first with plain water,, 
then with the Lysol solution, and finally exposed to the direct ray& 
of the sun for a day or two. 

The cubicle in which the box was to be fitted was thoroughly 
disinfected by washing down walls and partitions with the Lysol 
solution (sprayed on by means of a garden squirt), and as the terrace 
floors are entirely of cement, the same treatment was extended to 
them. 

Finally the two controls and two of the experimental animals failed 
to contract the disease, and would thus appear to afford proof of the 
efficacy of the disinfectant measures pursued. 



3. Feeding Eacperirnents with Naturally Infected Milk Alone, 

Series IV. — ^The same care was observed as in the earlier experiments- 
in picking out animals that were in good general condition, free from cuts 
and scratches, and irom whose blood serum specific agglutinins were 
absent. The method of preparation for the feeding experiments was 
identical with that adopted in Series I, and the infective material was 
again goats' milk derived from the herd of goats under observation at 
the Lazzaretto. In addition, the monkeys employed in this and the 
succeeding series had been trained to drink milk from the pannikin 
" human fashion." 

In the fourth set of experiments two monkeys only were employed, 
and these were each supplied with 500 c.c. of " whole " milk (in two 
equal quantities as in the previous experiments, the first at 9 A.M., the 
second at 11 A.M.), the one from Goat No. 114, the other from 



Digitized by VjOOQ IC 



58 Dr. Eyre, Major McNauglit, Capt. Kennedy, and Dr. Zammit. 

Goat No. 115, in order to imitate, as far as possible, the sequence of 
events taking place in a private household, where the housewife calls 
to a passing goatherd and receives into the receptacle she provides the 
milk from one goat for consumption by the family. Each of the goats 
above-mentioned had been under observation for some months, and was 
consistently passing J/. mAitfmk in its milk. Samples of each of these 
milks were diluted and plated, and on enumeration after incubation it 
was found that the milk from Goat No. 114 contained 800 M, vieUtensU 
per cubic centimetre, and that from Goat No. 115, 300 per cubic 
centimetre. 

The milk was set )>efore the experimental monkeys in pannikins, as 
in the three former experiments, but, as the animals were shut up in 
mosquito-proof cubicles, it was difficult to ascertain how much, if any, 
of the milk had been consumed. With regard to Monkey No. 197, 
however, it is certain that she ingested at any rate 45 c.c. of the milk 
from Goat No. 114, as owing to a mistake on the part of an assistant 
she was anaesthetised diuing the morning, and a soft rubber catheter 
passed into her stomach before the error was noticed. Under the 
•circumstances it was deemed advisable to introduce a further dose of 
the milk she had presumably drunk earlier in the day into her stomach 
before allowing her to recover from the anaesthetic, and this was 
Accordingly done. Monkey No. 196, on the other hand, only ingested 
fluch quantity of milk as she had voluntarily drunk from her pannikin. 

Two monkeys which sened as "controls" for this and the two 
following series each received 500 c.c, and consumed about 50 c.c. of 
sterilised goats' milk. 

Of the two animals fed on infected whole milk. Monkey No. 197, 
which must certainly have received a larger dose of infected milk, and 
milk moreover which contidned at least double the number of cocci per 
cubic centimetre, showed a definite reaction four days before her fellow 
43ufferer, that is on the 17th day. Monkey No. 196 showing a definite 
reaction on the 21st day. Exactly one month after feeding. Monkey 
No. 197 and one of the controls, 189, were chloroformed and careful 
examinations made of the bodies, with the result that no evidence of 
infection by J/. melUends could be obtained in the case of the control, 
whilst Monkey No. 197 yielded M, liieliiensis from all the organs 
examined, although the coccus was absent from the small quantity of 
heart blood that was plated. 

The Monkey No. 196 was chloroformed on the 33rd day, when the 
blood senun gave an immediate and unmistakable positive reaction in 
dilutions of 1 in 100. The pmUrnortem examination showed greatly 
enlarged liver and spleen, each organ being studded with tubercles, 
many of which were caseous. The superficial lymphatic glands were 
also enlarged. Cultivations established from the blood and the organs 
gave rise to a plentiful growth of various bacteria, but no M, melitensis 



Digitized by VjOOQ IC 



Bact4!rwlogi4xd and E,xp€i%7neiUal Investigations^ 1906. 59 









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July 27. 



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60 Dr. Eyre, Major McNaught, Capt. Kennedy, and Dr. Zammit. 

could be detected or recovered. While in this case there is not 
a shadow of doubt in the minds of the experimenters that the 
monkey had been successfully infected, the coexistence of abdominal 
tuberculosis had exercised such a profound influence on the course of the 
disease as to render the absolute proof of the existence of infection, viz.^ 
the recovery of M, meliiensis from the various organs past mortem 
impossible to obtain, and this animal must consequently be eliminated 
from the experiment. 

The second control, which was killed on the 48th day, showed no- 
signs post mortem of infection with M, melitensis and at no period during 
the course oi the experiment could specific agglutinins be detected in its 
blood serum. 

The net result of this experiment, however, is still to conclusively 
prove that infection may result in the monkey (e,g,, No. 197), after the 
ingestion of one quantum of naturally infected milk, and that not a 
grossly contaminated sample, with an incubation period of about 
17 days. 

Series V, — In the next experiment an attempt was made to reproduce 
the conditions obtaining in the case of a hospital, barracks or other 
large institution supplied with goats' milk by a contractor who would 
necessarily command the daily milkings of a large number of goats and 
who would, for the convenience of all parties, supply " mixed " milk in 
chums of several gallons capacity. 

Experience based upon the examination of the milch goats in a large 
number of herds from all parts of the island had already shown that 
a typical herd consisted of something like 60 per cent, normal goats 
yielding milk free from contamination with M, melitensis ; 30 per cent, 
of goats previously infected (and whose milk yields a definite aggluti- 
nation reaction), but which are either completely convalescent or else 
are in an early stage of the disease and are consequently not discharging 
the specific micro-organism in the milk ; and 10 per cent, of goats whose 
milk not only gives a strong agglutination reaction, but also contains 
M, melitensis in varying numbers. 

The infective material in this experiment was consequently made up- 
in the following manner : — 

Three perfectly healthy goats which gave no evidence of having been 
infected with M, melitensis were milked to the extent of 1 litre each 
into a sterile bottle. 

Ooats Nos. 101, 108, 110, whose milk gave a good agglutination 
reaction, but although plated regularly several times a week for some 
months had never yet yielded M, melitensis, were milked, also in sterile 
bottles, to the extent of 500 c.c. each. Goat No. 117, whose milk gave 
a good agglutination reaction and invariably yielded M, melitensis when 
plated, in numbers ranging from a few hundreds to thirty thousand and 
upwards per cubic centimetre, was milked to the extent of 500 c.c. into- 
another sterile bottle. 



Digitized by VjOOQ IC 



Bdderiological aiid Experimental Investigations, 1906. 61 

Taking 500 c.c. as the unit of measurement, two volumes of milk 
from each of the three first goats were mixed with one volume from 
each of Goats Nos. 101, 108, 110 and 117, thus forming a fairly 
representative "mixed" milk such as would be obtained from an 
average herd. 

Before the mixing was actually carried out, centrifugalised samples 
or suitable dilutions from the milk of each goat were plated out, and 
after the usual period of incubation and observation the following 
results were obtained : — 

Ooat 117. Agglatination reaction positire. Contained approximately 1000 

Jf. melitenjtis per c.o. 
,, 101. ,, ,, „ Contained no Jf. ffi«Z»^e}i«tff. 

•» 110. „ „ „ „ „ 

„ 2. „ ,. negatiTe „ „ 

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Samples of the " mixed " milk plated after mixing gave an average of 
100 M. mditensis per cubic centimetre. 

Two hundred and fifty cubic centimetres of this " mixed " milk 
were supplied to each of five experimental monkeys at 9 A.M. It was 
impossible, however, to see what was going on inside the mosquito-proof 
cubicles and, as much of the milk was wilfully wasted by the animals, 
a further quantity of 250 c.c. was filled into each monkey's pannikin 
at 1 1 A.M. At one o'clock the pannikins were removed, sterilised and 
refilled with a feed of boiled rice. From this point onwards the 
ordinary method of feeding was resumed and no more infective 
material was administered. 

Of this batch of five animals, one (191) was found a few days after 
the feeding to be prostrate and helpless. It refused all food, ran a 
markedly intermittent temperature, and was foimd dead on the 10th 
morning. No serum reaction had been exhibited by this animal during 
its lifetime, and post-mortem examination failed to reveal infection by 
AT. meUtensis, or indeed any obvious cause for death. This animal must 
consequently be disregarded and is not included in the table dealing 
with this experiment. 

Of the remainder, Monkey No. 195 first yielded a positive serum 
reaction (1 : 10) on the 17th day, Monkey No. 194 on the 18th day 
and Monkey No. 192 on the 21st day. The first Monkey (No. 195) 
pursued a remarkable course. From the 17th day onwards the dilution 
in which the serum reaction was obtainable steadily rose until on the 
25th day it had reached 1 in 100. At the end of the third week blood 
was extracted from the external saphenous vein of each of the monkeys 
comprised in Series FV, V, and VI and planted in broth. Two days 
later all the tubes were found to be badly contaminated, with the 



Digitized by VjOOQ IC 



62 Dr. Eyre, Major McNaught, Capt. Kennedy, and Dr. Zammit 






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open pannikin at 9 A.M., and a farther 250 c.c. 
at 11 A.M., Jnly 27. 



Not more than 50 co. of mixed milk 
from healthy and infected goats 
(Nos. 102, 108, 118, 101, 108, 110, 
and 117) oontaining 100 M, meli^ 
Unfit per c.c. 



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Two meals daily, July 28, 24 and 25, consisting of 
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exception of those planted with blood from Monkey No. 195. 
These tubes were plated out and yielded a scanty growth of 
M. melitensis. The serum reaction then fell rapidly and on the 32nd 
day an incomplete reaction was all that could be obtained with 1 : 20 
dilution. When killed on the 38th day agglutinins appeared to be 
absent from the blood serum, as no reaction could be obtained even 
with 1 : 10 solution. Cultivations from the various organs remained 
sterile and the non-recovery of M. ineHtemis^ 2)osi'rnortcrny would appear 
to indicate that the infection was of a very mild and transitory type. 

Another Monkey (No. 193) showed no sign whatever of infection 
throughout the course of the experiment, no trace even of agglutinin 
was present in its blood senun up to the date of the termination of the 
experiment on the 48th day, when it was chloroformed and examined 
post-mortem, M, melitensis was not recovere<l from any of its organs. It 
is, of course, possible, but not probable, that the monkey refused to 
take any of the infected milk and the absence of infection may be due 
to this cause, or to absolute continuity of the mucous membrane of the 
upper portion of the alimentary tract, but these are pure speculations. 
The fact remains that this monkey did not become infected by 
3/. melitensis. 

The two remaining monkeys (Nos. 194 and 192) when killed on the 
31st and 33rd days respectively, afforded abundant evidence of 
generalised infection, so that as the net result of this experiment it 
may be stated that three out of four monkeys became infected as the 
result of each ingesting a quantity of mixed milk, containing not more 
than 5000 M, melitensis. 

The full details of the results obtained are given in tabular form (p. 62). 

Series VI. — As in all the preceding experiments, it may be urged that 
infection took place not through the intact mucous membrane of the 
alimentary canal, but through some lesion, perhaps only microscopic in 
extent, of the mucous membrane of the mouth ; in this experiment an 
attempt was made to differentiate between such and direct absorption 
through the presumably intact mucous membrane of the stomach and 
intestinal walls. Two monkeys were, therefore, selected and prepared 
for the experiment in a manner precisely similar to that adopted in the 
other experiments ; Monkey No. 198 was carefully anaesthetised with an 
AC.K mixture (alcohol, 1 part ; chloroform, 3 parts ; ether, 6 parts) 
and when fully unconscious, his mouth gently opened and a wooden 
gag introduced and fixed behind the canine teeth. The tongue was 
then pulled forward and a No. 8 soft rubl>er catheter passed down the 
oesophagus into the stomach. A small funnel was inserted into the 
open end of the catheter and 45 c.c. of " whole " milk from Goat No. 117, 
containing 1000 M, melitensis per cubic centimetre poured through into 
the stomach. Half a minute later the catheter was washed through 
with 10 c.c. of sterile salt solution, and after another short interval the 



Digitized by VjOOQ IC 



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Bacteriological and Experimental Investigations, 1906. 65 

open end of the catheter was clipped and the instrument carefully 
withdrawn. On removing the pressure from the upper end of the 
catheter nothing but a few drops of clear saline solution flowed from 
the eya The animal was kept under the influence of the anesthetic 
for a further period of five minutes, then gradually allowed to come to. 
No regurgitation of milk took place and the monkey was soon 
sufficiently recovered to be returned to his cubicle. By similar means, 
Monkey No. 199 had 45 c.c. of whole milk from Goat No. Ill, 
containing 4000 M, melitensis per cubic centimetre introduced into his 
stomach and in this instance also regurgitation of the food was absent. 

Of these two animals, Monkey No. 199, which had received some 
180,000 M, meliteTisiSy showed no signs of the formation of specific 
agglutinins throughout the entire course of the experiment, and when 
killed and examined post-mortem on the 42nd day the cultivations pre- 
pared from the various organs remained sterile. Monkey No. 198, 
which had received 45,000 3L mUUensis, yielded on the 17th day a 
very incomplete reaction with 1 in 10 solution of blood serum. A similar 
incomplete reaction was noted in the same dilution on the 21st and 
25th days. No further reaction was obtainable, and when the animal 
was killed on the 42nd day, the cultivations prepared from the various 
organs — like those from Monkey No. 199 — remained sterile. This 
experiment therefore yielded completely negative results. In neither 
case did the introduction of fairly large numbers of M, melitensis into 
the stomach direct — avoiding any contact with the mucous membrane 
of the upper portion of the alimentary canal — result in the infection of 
the experimental animal. As the experiments comprised in Series IV, 
V, and VI were carried out on the same day and under exactly com- 
parable conditions. Monkeys No. 189 and 190 have done duty as 
controls to all. 

The details of this experiment are shown in Table XVIII (p. 64). 

4. Clinical Featvres of Food Infections in the Monkey. 

On the clinical aspect of the infection produced by these feeding 
experiments it is unnecessary to dwell at length or to reproduce tempera, 
ture charts in detail. A few points of interest may, however, be briefly 
mentioned : — 

Temperature, — Speaking generally, the infection, as judged by the 
course of the animal's temperature and supported by its general appear- 
ance and behaviour, appeared to be far from severe during the six or 
seven weeks some of the animals were under observation, but opinions 
based upon clinical symptoms were rudely contradicted by the result of 
the post-mortem examinations. 

In this connection it is necessary to emphasise the ready response 
of the temperature of the monkey to environmental conditions. The 
normal temperature of the Khesus when confined in the cool, quiet 
(13984) / 



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66 Dr. Eyre, Major McNaught, Capt. Kennedy, and Dr. Zammit. 

rooms of the Lazzaretto and attended by a man accustomed to handle 
such animals and thoroughly acquainted with their habits, averages 
about lOr F., although such extremes as 99°*2 in the morning and 
103''"4 in the evening have been noted. (The temperatures are here 
given in Fahrenheit degrees for the sake of uniformity with the tem- 
perature charts recorded in previous parts of these Beports.) When 
transferred to the hot, simny terraces outside the Laboratory — overlook- 
ing, perhaps, the noisiest street in Valletta — and handled by a new and 
ignorant attendant, who at first obviously went in fear of his charges, 
the normal temperature became probably half a degree higher. When, 
as sometimes happened, the animal was allowed to resist capture and 
to struggle for some minutes before it was sufficiently firmly held to 
allow of its temperature being taken, the resulting reading was some- 
times as much as 2° F. too high. Under such conditions as these, febrile 
temperatures are apt to be fallacious imless very rigorously scrutinised, 
and to illustrate these irregularities of the temperature curve, the chart 
of one of the normal healthy controls — Monkey No. 172 — may be 
utilised. 



Chart 6. 

Another point to be noted with regard to the even temperatures 
many of the experimental monkeys exhibited, is that, owing no 
doubt to the strictly enforced cleanliness of the monkeys and their 
habitations, and the minute attention devoted to the quality of their 
food, the cases were uncomplicated by diarrhoea and gastro-intestinal 
disturbances, which are, perhaps, the most fruitful causes of febrile 
reaction in the monkey. 

Again, speaking generally, the temperature chart of the Khesus 
infected with M, melitensis, except in the case of very severe infections 
such as follow intercranial injections of the micrococcus, shows but one 
period of pyrexia, followed by an intermittent temperature of slight 
range and short duration. A second period of pyrexia, or *' wave " as 
it is colloquially termed, is quite the exception. The remittent type of 
pyrexia does, however, occur in the monkey ; also this animal some- 
times exhibits a type of temperature absolutely comparable to the one 
obtaining in man, when the subject of what Shaw has designated the 
" ambulatory " type of Mediterranean Fever. 



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Bdcteriological and E^erimental Investigations, 1906. 67 

Taming now to concrete examples, the temperature charts of Monkeys 
Nob. 153, 164, and 155 have been selected to illustrate the three types 
above referred to, and, although y&rying so widely in clinical aspect, 
the severity of the infection must have been of nearly equal intensity 
in these cases, judging by the results of the bacterioscopic examination, 
which showed that the blood and all the organs of these animals were 
literally teeming with the M, melitensis. 



Chart?. 



Chftrt 8. 



Chart 9. 

Aggluiinatian JteaeOon. — The repeated examinations that were made of 

blood from each of the infected monkeys showed that for a day or two, 

or even several days, before a definite reaction was obtainable, a 1 : 10 

dilation of the serum produced what is regarded as an " incomplete " 

(13984) / 2 

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68 Dr. Eyre, Major McNaught, Capt Kennedy, and Dr. Zammit. 

reaction — that is, the micrococci ceased to exhibit active vibratory move- 
ment and adhered together in small bunches, but large clumps and masses 
were not formed and the general field was made up of discrete cocci. 
Then a good reaction, large clumps in a perfectly clear fluid, readily 
visible with the two-thirds lens or, indeed, the unaided eye, would be 
produced by a low dilution of the senun — 1 : 10 or 1 : 20. Very 
often, even at this stage, the macroscopical reaction in the sedimenta- 
tion tube was absent Next, the microscopical reaction would often 
disappear for a day or two, or even longer ; finally, it would become 
firmly established and obtainable in the majority of cases in consider- 
ably higher dilutions, and the micro- and macroscopical reactions would 
control and confirm each other with absolute precision. The exigencies 
of experiment necessitating the destruction of animals early in the 
course of the disease are responsible for the fact that but few examples 
of the development of a very high agglutinative power in the serum 
were noted. 

5. The Action of Hydrochloric Acid and of Artificial Gastric Juice on 
M. melitensis. 

During the progress of these experiments, an investigation into- 
the action uf hydrochloric acid alone and also of artificial gastrie 
juice upon the M, niditensis was undertaken. In the first instance,, 
l-per-cent solution of hydrochloric acid to the amount of 5 c.c. was 
mixed in a sterile test-tube with a like volume of emulsion, in normal 
saline solution, of cultivation of M, melitensis, the emulsion being 
approximately of the strength of 1 milligramme of cultivation to 
100 c.c. of saline solution, or, expressed in individual cocci, about 
2,000,000 of M, melitensis per cubic centimetre ; 5 c.c. of the emulsion 
mixed with an equal quantity of 010 per cent, hydrochloric acid were 
put up in a second tube, 5 c.c. of the emulsion of ^f, melitensis mixed 
with an equal quantity of 0*05 per cent, hydrochloric acid solution were 
put up in a third tube, and a control was prepared by mixing 5 c.c. ot 
normal saline solution with 5 c.c. of the emulsion in a fourth tube. 
Immediately after mixing, a loopful of the contents of each tube was 
plated out and the tubes transferred to the incubator at 37' C. At 
intervals of 5, 10, 15, 20, and 30 minutes, and also after one and two* 
hours' incubation, further similar plates were prepared from the mixture 
in each tube, and, after the usual period of incubation and observation, 
each of the plates was carefully studied. Many variations were made 
in the percentage strength of the hydrochloric acid solution and in the 
number of cocci per cubic centimetre of the emulsion, and the mixtures 
were similarly tested. The results obtained were fairly uniform and 
showed that when the very large numbers of cocci were suspended in 
weak solution of the acid, very little lethal action was demonstrable. 

On the other hand, it will be seen from the experiment tabulated 



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Bacteriological and Experimental Investigations, 1906. 69 

below, which is a tjrpical one, that M. melUensis, when present in an 
aqueous solution of the acid in moderate numbers only, while able to 
withstand the lethal action of a 0*025-per-cent. solution of hydrochloric 
acid as well as of 0'05-per-cent. solution for considerable periods, is 
destroyed by 0*5-per-cent. solutions within an hour : — 

Table XIX. — The Action of HCl upon Watery Suspensions of 
if. melUensis, 



Compoeition of mixture : — 
Bftotenal emulsion uid lolution 

of Ha 


Percentage 
of HCl in 
mixture. 


Time of contact. 


Imme- 
diate]/. 


45 
mins. 


60 
mins. 


2 
hrs. 


6 o.c. + 5 c.c. of 1 per cent 


0-6 
06 
0*026 


+ 
+ 
+ 


± 
+ 
+ 

+ 


+ 


+ 
+ 


6 c.c. + 5 C.C. of 0*1 per cent. 

6 C.C. + 5 c.c. of 0-05 per cent. 

Control. 

5 ce. emulsion of cocci + 6 c.c. of 
•aline solution 





+ ■" Oood growth, ± ■■ Scanty growth, — — No growth. 

Next, a couple of sterile flasks were taken and 25 c.c. of milk from 
Goat No. 115, containing some 2500 M, melUensis per cubic centimetre, 
was introduced into the interior of one, and 25 c.c. of artificial gastric 
juice added and thoroughly mixed. The composition of the artificial 
gastric juice was : — « 

Pepsin 0*32 gramme 

Hydrochloric acid 0*02 „ 

Sodium chloride 0*22 „ 

Sterile distilled water 100 c.c. 

A control was formed by mixing 25 c.c. of milk from Goat No. 115 
and sterile saline solution. 

After plating a loopful from each mixture to determine the number 
of micrococci present at the commencement of the experiment, the 
flasks were placed in the incubator at 37** C. At 15, 30, 60 minutes, 
2 and 24 hours, the flasks were removed from the incubator and about 
one-tenth of a cubic centimetre from the contents of each plated out, 
and after incubation the colonies of M, melitensis which developed were 
enumerated. 

One of the experiments — a representative one-— is tabulated below, 
and shows that the artificial gastric juice exerts some, although slight, 
inhibitory action on the growth of M. melUensis from the moment of 
contact. 



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70 Dr. Eyre, Major McNaught, Capt. Kennedy, and Dr. Zammit. 

Table XX. — The Action of Artificial Gastric Juice upon M. melUensis 
present in Naturally Infected Milk. 



MixtYire. 


Time of contact. 


Imme- 
diately. 


15 
mins. 


90 

mins. 


60 
mins. 


2hrs. 


25 CO. artificial gagtric juice + 
25 c.c. milk from Goat No. 115 

ControL 

25 0.0. normal saline solution + 
25 c.a milk from Goat No. 115 


420 
1890 


640 
850 


130 
2700 


250 
1800 


440 
8050 



The numbers gire the calculated jield of M. meliteuM per cubic centimetre. 

III. — M. melitensis Infection following the Ingestion of Infective 

Milk in Man. 

As an interesting and highly instructive corollary to the foregoing 
infections in the monkey, resulting from experimental feeding with 
infective milk, the occurrence of an epidemic of Malta Fever on board 
the S.S. " Joshua Nicholson," a cargo steamer, which conveyed a herd 
of milch goats from Malta to Antwerp towards the end of the summer 
of 1905, may be cited. Many of the officers and crew partook of the 
milk of these goats, and subsequent bacteriological investigations 
proved that some of these animals were infected by M. melitensis. 
As a result of the investigations made at the end of 1905 and during 
1906, there can be no reasonable doubt that the cases of Malta 
Fever reported from the ship were due to the ingestion of the 
infected milk. 

The history of the outbreak has been carefully compiled by Staff- 
Surgeon Clayton, and full epidemiological details, together with the 
history of each individual case so far as can be ascertained, is pre- 
sented in a succeeding Part of these Reports, but because the history, 
read in the light of the results recorded in the previous section, 
savours so strongly of a carefully planned laboratory experiment, 
a short rismrU is inserted here. 



RisunU OF THE Outbreak 
Board the s.s. 



OF Medfterranean Fever 
* Joshua Nicholson." 



ON 



1. History of the Goats. 

Mr. Thompson, of the United States Bureau of Animal Industry^ 
visited Malta in the summer of 1905, and during a stay of some 



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Bcuieriological and EocperiineTvtal Investigations, 1906. 71 

months gradually purchased a herd of 61 milch goats (all healthy in 
appearance and good milkers, many being prize animals), and four 
billy goats. These he shipped on board the cargo steamer " Joshua 
Nicholson," on August 19, 1905, for passage to the United States 
viA Antwerp. During the voyage, which lasted until September 2, 
1906, when Antwerp was reached, the goats were milking well, and 
many of the ship's company partook freely of the milk — the officers 
drinking "mixed "milk collected in a large vessel, the members of 
the crew each obtaining " whole " milk from one goat in his own 
separate pannikin. 

On arrival at Antwerp the goats were at once transferred to the 
quarantine station, where they remained for the five days that elapsed 
before they were re-embarked on the s.s. "St. Andrew" bound for 
New York, and during this voyage a large quantity of milk was 
again available for consumption. * New York was reached about 
September 24, and the animals were transferred to the quarantine 
station at Athenia, N.J., where they remained under observation. 
Subsequent bacteriological examination resulted in the recovery of 
if. meliiensis first from the milk of two of the goats and afterwards 
from that of several more. 

2. The Incidence of Mediterranean Fever among those who partook of the 

Milk. 

(a) In the s.s, '^Joshua Nicholson." — In addition to four passengers 
(Mr. Thompson and three goatherds) present on the voyage from 
Malta to Antwerp, the "Joshua Nicholson" carried 23 officers and 
men. Of the crew of 19, the carpenter, boatswain, and mess-room 
steward, together with eight others (11 in all), left the ship at 
Antwerp; the boatswain was afterwards in hospital suffering from 
hernia; the movements of the remainder cannot be traced. Of the 
12 remaining officers and crew, eight fell sick at intervals varying 
from 18 to 34 days from the embarkation of the goats, and in the 
cases of five of these eight the blood reactions leave no room for doubt 
that Mediterranean Fever was the cause of their illness. 

The four members of the ship's strength who did not show any 
signs of illness were the second mate and the cabin boy, with whom 
the milk disagreed and who consequently had but very little, and 
two engineers (Germans) who drank the milk, it is true, but appear to 
have always boiled it. 

Of the three goatherds, one (the chief goatherd) had undoubtedly 
been infected with M. melitensis previous to July, 1906, as evidenced 
by the presence of specific agglutinins in his blood, but whether 
recently or remotely it was impossible to say : about the two assistant 
goatherds no information could be obtained. 

(b) At Antwerp. — The staff of the quarantine station and many 

Digitized by VjOOQ IC 



72 Dr. EjTe, Major McNaught, Capt. Kennedy, and Dr. Zammit 

individuals in the neigbourhood are said to have partaken of the 
milk, both raw and boiled, during the five days the goats were 
interned here, but no information can be obtained of the subsequent 
occurrence of cases of illness resembling Mediterranean Fever. 

(c) In the 8.8, ''St, Andrew,''— The s.s. "St. Andrew" carried 
30 cattle men and the three goatherds and Mr. Thompson, in addition 
to a crew of 30 men. Most of these drank of the milk, but the 
master of the ship and also his owners state that none of the men 
suffered from any illness. 

(d) In America. — With the exception of Mr, Thompson, who died 
in January, 1906, from "bilateral pneumonia following influenza," 
and about whose medical history, qud Mediterranean Fever, no 
evidence can be obtained, only one person — a woman at the 
quarantine station — took the milk in any quantity. She, however, 
drank the mixed milk from several goats for a considerable period, 
and in December, 1905, suffered from a typical attack of Mediterranean 
Fever. 

3. The Remits. 

In summarising the result of this unpremeditated experiment, 
several factors have to be considered. For instance, a certain 
unknown number of goats — more, however, than two — were shown 
to be secreting infective milk after their arrival in America, some 
three months after leaving Malta, but there is no direct evidence as 
to the number whose milk contained M. melitensis during the voyage, 
in summer weather, from Malta to Antwerp. Arguing from analogy 
with average Maltese herds, at least six should have been secreting 
infective milk. The goats purchased by Mr. Thompson were, 
however, picked animals and heavy milkers, and as experience has 
shown that the goats yielding the most milk in any given herd are 
the most likely to be passing M. melitensvi in their milk, the proba- 
bility is that in this particular herd of 60 milch goats (one having 
died the day after leaving Malta) the milk from considerably more 
than six was heavily infected — an inference which receives confirma- 
tion from the fact that the three ofiicers and the steward who drank 
" mixed " milk each developed an attack of Mediterranean Fever, the 
remaining officer and the cabin boy, with whom the milk disagreed and 
who consequently did not drink it, remained well. 

The members of the crew, on the other hand, each drank " whole " 
milk from a single goat, and apart from the possibilities of the milk 
being supplied on any particular occasion from an uninfected animal, 
a reference to Section I (3), shows clearly the possibilities of a man 
who obtains milk, even from an infected animal, avoiding the ingestion 
of infective milk. 

Apart from such considerations, however, it suffices to state the net 
result as follows : — 



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Bacteriological and Experimental Investigatiom, 1906. 73 

Of 23* men on board the 8.8. " Joshua Nicholson " who drank on 
one or more occasions presumably infected milk, no evidence whatever 
is available as to 12 and no relevant information as to Mr. Thompson ; 
of the remaining 10, one suffered from hernia only, one was infected 
by M, melUensis at an unknown date, while eight suffered from febrile 
attacks — 5 (or 50 per cent, of them) yielding conclusive evidence of 
infection by M. melUensis. 



rv. — The Rdle of the Mosquito and other Blood-sucking Insects 
IN the Dissemination of M. melitensis. 

That the mosquito may act as the vehicle in the conveyance of the 
infection of Mediterranean Fever may be an example of the wish 
being father to the thought, and due in part to the inconvenience 
caused to residents in Malta by these little pests. The rise in the 
case-incidence curve of the disease in June, July, August and 
September, t roughly corresponding as it does to the mosquito season, 
gives colour to a suggestion which is by no means new. In 1902 
Zammit produced detailed evidence of an epidemiological character in 
support of the mosquito theory — that is to say before this observer 
had noted the natural infection of goats — later on Zammit, Horrocks 
and Kennedy produced experimental evidence of similar tendency, 
and more recently still Ross has laboured the point on purely 
theoretical grounds. 

Before, however, attacking the question of the conveyance of 
3f. melUensis infection, it became necessary to study the species of 
mosquitoes prevalent in Malta, since it seemed possible, arguing from 
analogy, that some one particular species, and one only, acted as 
the vehicle. 

1. Species of Mosquitoes occurring in Malta. 

Six species, representing five genera and two sub-families, are of 
common occurrence, viz. : — 



Culex fatigans 

Culex pipiens 

Theobaldia spathipalpis, . . 
Acariomyia ZammUii . . . 

Stegomyia fasciaia 

Anopheles maculipennis Sub-family Anophelina. 



Sub-family Culicina. 



and apart from Anopheles, which is restricted at present, so far as 
breeding place is concerned, to one valley in the centre of the island, 

* That is disregarding the two men who boiled the milk before drinking it, and 
the officer and cabin boj who did not drink the milk, 
t JohnstonCi these Beports, II, p. 86. 



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74 Dr. Eyre, Major McNaught, Capt. Kennedy, and Dr. Zammit. 



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76 Dr. Eyre, Major McNaught, Capt. Kennedy, and Dr. Zammit. 



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Bacteriological and Experimental Investigations, 1906. 77 

and Acartom3da, which breeds along the coast line, these species are 
fairly uniformly distributed over the entire island. 

The accompanying synoptical table, adapted from Theobald in 
accordance with observations made in Malta during the summer of 
1906, details the chief points of similarity and distinction between 
the various mosquitbes, and is introduced here in the hope that it 
may prove helpful to workers in Malta in this or similar fields. 

2. Supply of Mosquitoes and Notes on their Habits in Captivity, 

The supply of insects required for the experimental work in 
connection with the attempts to transmit M, melitensis infection by the 
aid of mosquitoes was kept up by repeatedly collecting large quantities 
of larvsB and pupse, transferring them to shallow glass dishes of water 
and allowing them there to complete their development — each species 
being confined in a separate gauze covered breeding-cage provided 
with two soft gauze sleeves (of sufficient capacity to admit the hand. 
and arm), situated in the front of the cage and so permitting ready 
access to any part of the interior. To facilitate the entry of the 
hand, the free extremity of the long sleeve was attached to a circle of 



Fie. 3.— Mosquito Breeding Cage. 

wire. By twisting the sleeve upon itself and pushing the wire circle 
under a tightly stretched piece of elastic (attached to the front of the 
cage) the imagines were effectually prevented from escaping (fig. 3). 
With adequate care, in such a cage the mortality of imagines when 
they emerged from their pupa cases was by no means excessive, and 
after being fed on blood the impregnated females readily laid their 
eggs in the water in which they had passed the early stages of their 
existence. 

The morning of the day preceding a feeding experiment the perfect 
females were captured in detail and each transferred to a short length 
of glass tubing (4 to 6 cm. long by 1*5 cm. in diameter) covered at 



Digitized by VjOOQIC 



78 Dr. Eyre, Major McNaught, Capt. Kennedy, and Dr. Zammit. 

one end with a piece of muslin secured by an indiarubber band and 
closed at the other by a well-fitting cork, where they remained, 
without food, for from 30 to 32 hours. This useful little piece of 
apparatus (fig. 4) enabled a distinguishing number or letter to be 
assigned to every mosquito, simplified the handling of the insects, and 
rendered it an easy matter to ascertain that feeding had actually taken 
place, and indeed to watch the entire progress of the act. 




Fio. 4. — Experimental Feeding-tube for Mosquitoes. 

In connection with these experiments many difficulties, varying 
with the species, were encountered, some of which may be usefully 
referred to. 

In the first place, cannibalism is a marked feature of mosquito life 
during the larval stage, of all the species, and probably not more than 
50 per cent, of the larvae — under laboratory conditions — attain 
maturity. The occasional addition of a few grains of tapioca to the 
water containing the larvsB certainly reduces, but by no means prevents, 
this wastage. 

Then it was soon found that female Acartomyia and sometimes 
Culex (faiigans and pipiens) when segregrated immediately after 
emerging from the pupa were weakly, could not under any conditions 
be induced to bite, and soon died. This reluctance of the virgin to 
auck blood has frequently been noted, and it was consequently found 
necessary to allow the females to remain in company with the males 
for two or three days after emerging from the pupa in order to ensure 
an adequate supply of impregnated females, the insects being freely 
supplied with fruit — chiefly apples — and syrup during this period. 
By adopting this method the weakly imagines, which quickly died, 
were weeded out and a supply of sturdy females was insured. 

Again, Acartomyia, although naturally a voracious feeder during the 
daytime as well as after dusk, like Culex could not in captivity be 
induced to bite untU after dusk and occasionally until after night was 



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Bacteriological and Eocperimental Investigations, 1906. 79 

well advanced. Captive Stegomyia, oa the other hand, bit readily at 
any time during the 24 hours. 

In feeding moequitoes a large fund of patience is required. Some, 
particularly* Stegomyia, will go down as soon as applied to the skin 
and commence feeding at once; others, like Acartomyia, are a 
considerable time testing area after area of skin with the proboscis 
before a suitable spot is found and the actual abstraction of blood 
begins. Individuals again may have to be coaxed before they will 
begin operations by shading the tube in which they are confined from 
the direct light, or by raising its internal temperature by closely 
encircling it with the hand. 

Having commenced to feed, the time taken by various individuals 
to completely fill themselves varies largely and bears no direct 
relationship to the size of the insect. A presumably thirsty 
Stegomyia will sometimes fill itself inside 30 seconds, another of 
apparently equal capacity, or the same individual on another occasion 
will require some 15 minutes to reach the stage of repletion: 
Acartomyia usually requires from one minute to five minutes to 
complete the meaL Hie shortest time noted was achieved by one of 
the largest Stegomyia in our possession, which required only 15 seconds 
to appease its appetite. 

The quantity of blood taken up by the insect at one feed is also 
a matter of some importance, for the minimal quantity of blood from 
Malta Fever patients in which Gilmour and Shaw* were able to 
demonstrate the presence of M, melitensis was approximately 3 and 
4 cubic millimetres respectively. Hie micrococcus may, however, be 
present in the blood of human patients in much greater numbers than 
these figures would seem to indicate {vide p. 125), as shown by the 
examination of the blood in a small series of cases this summer, when 
M. melitensis was once foimd to the number of 10,000 per cubic centi- 
metre — a quantity of infective material in the blood stream comparing 
with that found in mild cases of malaria or very severe cases 
of streptococcic septicaemia. 

Estimations were therefore made by weighing one of the empty 
mosquito tubes, transferring a captured mosquito to its interior and 
again weighing it — the difference being taken to represent the weight 
of the insect. The mosquito was immediately fed and again weighed, 
the difference in the weights of tube pltis mosquito, before and after 
feeding, being regarded as the weight of the blood ingested, and may 
fairly be taken as sufficiently accurate for practical purposes. From a 
series of eight such weighings the average quantity of blood taken 
up by Stegomyia was 3 milligrammes, the extremes noted being 
1*5 milligrammes and 5'5 milligrammes. Stegomyia fasciaia was the 
species selected for the purpose of this experiment, on account of the 
• Vide these Reporto, I, p. 10, and III, p. 19. 



Digitized by VjOOQ IC 



80 Dr Eyre, Major McNaught, Capt. Kennedy, and Dr. Zammit. 

readiness with which this insect bites even during the day time. Thus 
all the operations of weighing, feeding, and again weighing could be 
carried out out during the middle of the day, when the air tempera- 
ture was at its maximum, and the air humidity, which is alh important 
factor in Malta, where delicate weighings are involved, at its lowest 
point. The details of these weighings are given in tabular form 
below. 

The amount of blood taken by a mosquito bears relationship to the 
elasticity of the skin of the abdomen rather than to the size of the 
insect, for of the two extremes noted the maximum, 0-0055 gramme 
blood, was ingested by a very small female — much smaller, in fact, 
than its weight (empty) would indicate. 

Table XXII. — Showing Average Weight of Stegomyia famaia before 
Feeding, and of Blood Ingested when the Insect was filled to 
Repletion. 



No. 


Weight of fasting 
mosquito. 


Weight of 

mosquito plus 

blood— after 

feeding. 


Weight of blood 
ingested at one meal 

(deduced from 

difference in weiffhte 

giren in Cols. 11 

and IV). 


1 
2 
8 

4 
5 
6 
7 
8 

Arerage 


gramme. 

0020 

0-0020 

0-0020 

0-0080 

0-0030 

0-0080 

0-0020 

0-0010 


gramme. 

0035 

0-0056 

0-0066 

0-0072 

0-0085 

0-0105 

0-0045 

0-0035 


gramme. 
0-0015 
0-0035 
0-0045 
0-0042 
0-0055 
0-0025 
0-0025 
0-0026 


00262 


0-00621 


0-00388 



3. The Duration of Life of M. melitensis in the Body of the Mosquito, 

Since the species of mosquito common to the Island as a rule only 
feed upon the human subject at intervals of 48 hours, the first and 
most important points for consideration were (1) whether the mosquito 
would serve as a host for the micro-organism, and if so (2) the 
duration of life of the M. melitensis in the insect's body. 

Previous workers* had isolated M, melitentis from the bodies of four 

mosquitoes (captured in the wards of hospitals where they had had 

opportunities of biting patients suffering from Malta Fever as well as 

patients suffering from other diseases, and also normal individuals)^ 

* Horrocks and Kennedy, vide these Beports, IV, p. 72. 



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Bacteriological aiid Expert tiuiital Investigaiimis, 1906. 81 

out of a total of 450 which they had dissected, and therefore dis- 
regarding the possibility of accidental external contamination of the 
mosquitoes, it was assiuned to be proved that the mosquito could act 
as a host for M. melUensis, thus disposing of the first point. 

With regard to the second point, the simplest method of determining 
the duration of life of the micro-organism within the insect's body 
would have been to feed a large niunber of mosquitoes simultaneously 
upon a patient suffering from Mediterranean Fever in whose blood 
M, meliteims was known to exist in large numbers ; then to dissect 
several mosquitoes at regular intervals and prepare plate cultivations 
from the contents of the stomach, etc. The difficulties in carrying out 
such an experiment were great. Cases of Mediterranean Fever in the 
wards of the Military and Naval Hospitals were few in number and 
mild in character ; moreover, Gilmour and Shaw had stated that the 
micrococcus could only be isolated from comparatively large quantities 
of blood, and that its presence was by no means constant. On 
liumanitarian grounds, too, it did not appear justifiable to subject 
Any one patient to the discomfort of being thus bitten by scores of 
mosquitoes in the prosecution of what were, after nil, but preliminary 
observations. 

Advantage was, therefore, taken of the fact that an extremely acute 
septicaemia, associated with the presence of numerous cocci in the 
peripheral circulation, can readily be induced in the guinea-pig by 
means of intracerebral inoculation of highly virulent cultivations of 
M, mditensiSy* consequently this animal was substituted for the human 
subject and, with this modification, the experiments suggested above 
were initiated. 

The procedure adopted was as follows : — 

At 8 or 9 A.M., two or three guinea-pigs were successively anaesthe- 
tised and injected intracranially with O'l of a loop of a 24-hour-old 
•culture of the highly virulent culture emulsified in 005 c.c. Advantage 
was taken of the insensibility of the animal to epilate a fair-sized area 
of the skin of the back between the shoulders. The temperature of the 
animal was then carefully watched. Usually, five or six hours later, or 
by 5 P.M. at latest, the temperature had reached 105° or 106** F., 
-and was maintained at this level for many hours ; with such a tem- 
perature it was known, as a matter of experience, that the circulating 
blood contained numerous cocci. The mosquito tubes already 
described, each containing an impregnated female mosquito, were then 
applied in turn, gauze covered end downwards, to the guinea-pig's 
back over the area of skin previously denuded of hair, and the insects 
allowed to fill themselves with blood. Immediately the entire batch 
of insects had fed, several insects were killed by ether vapour, placed 
in sterile Petri dishes and dissected at once. The bloody contents of 
* Eyre, vide these Beports, II, p. 75. 

(13984) g 



Digitized by VjOOQ IC 



82 Dr. Eyre, Major McNaiight, Capt. Kennedy, and Dr. Zauimit. 

the stomach were removed and emulsified with a small quantity of 
sterile salt citrate solution (0"76-per-cent. sodium chloride and 1-per- 
cent, sodium citrate in distilled water) and distributed over the surface 
of three or more nutrose-agar plates. After incubation, the colonies of 
M, melitensis that had developed were enumerated and their identity 
verified. This process was repeated at regular intervals, two or three 
insects being destroyed every 24 hours or so, and the contents of their 
stomachs plated, the unused insects l>eing kept in a cage containing a 
vessel of water in which to lay their eggs, and supplied with fresh 
fruit, or retained in the separate feeding-tubes into which smaU cube» 
of apple or other fruit were introduce ddaily. In this way it was 
determined that the numbers of M, mHitensis usually decreased as time- 
went on, the greater number being voided with the droppings in the 
first 48 hours after feeding, but that in one or two instances the cocci 
appeared to actually multiply in the mosquito's stomach for a day or 
two, while it was certainly proved that living micrococci could l>e- 
demonstrated in the interior of the mosquito four days after feeding on 
an infected animal. 

4. Experiments vM Acartomyia Zammitii. 

The distribution of Acaiimnyia Zammitii^ restricted as it appears to- 
be to the Mediterranean littoral, and so corresponding to the chief 
incidence of Malta Fever, is held ]»y some to give to this unique 
mosquito an especial claim to the carriage of the specific micro-organism 
of the Fever ; and as moreover it is the first mosquito to appear in early 
siunmer in any considerable numbers, attention was first directed to it. 

This insect, which has only comparatively recently been recognised as^^ 
a distinct entity (being formerly regarded as a common Culex), is. 
peculiar in that the early stages of its existence, from ovum to pupa, 
are passed in salt water. All around the coast line of the Island are^ 
rock pools above high-wawr mark filled with salt water, but not in 
direct communication with the sea, legacies of the stormy Grigali, a 
north-east wind which prevaib from October to April. These pools 
remain isolated throughout the summer, and the contained salt water 
]>ecomes highly concentrated from the evaporation that takes place 
during the hot weather. 

The Acartomyia season begin.s in April or May, and is abruptly 
terminated by the first Grigali of winter. The larvae of Acartomyia 
are to be found in practically all these rock pools, but are especially 
numerous in the half natural, half artificial salt pans in the neighbour- 
hood of the northern and eastern coasts of the Island. It is interesting 
to note that a certain amount of discrimination is exercised by the 
female in the selection of water in which to lay her eggs. Sea 
water from the Mediterranean contains a larger percentage of salt 



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Bacteriological and Eocperimental Investiffatiom, 1906. 88 

(2*72 per cent, sodium chloride) than open seas, and the average 
content of the more concentrated pools in which larva and pupn are 
most abundant reaches a still higher figure (7'68 per cent.). Many 
attempts were made to induce the captive female to lay her eggs 
in fresh water or in ordinary sea water, but without success. 
Immediately, however, salt water of the necessary density was placed 
in the cage the eggs were deposited therein, even when the water was 
in a large glass vessel and had neither seaweed, cUhriSy or empty pupa 
cases upon which the insect could rest during the process, and so was 
drowned at its termination. Again, if three vessels of water were 
placed simultaneously in a breeding cage containing females ready to 
lay their eggs, the first filled with fresh water, the second with 
ordinary sea water, and the third with concentrated salt water, all the 
eggs would be found deposited in the concentrated salt water within 
24 hours, and none would be present in either of the other two vessels. 
The eggs are pointed ovals, averaging 0*5 mm. in length, white when 
first laid, but rapidly becoming brown and then black. They are laid 
singly or in pairs, or most commonly in rows resembling palisades, 
the individual eggs being arranged side by side. Under the ordinary 
conditions of nature, that is free exposure to air and sunlight, the 
eggs hatch out in from 24 to 72 hours. If transferred to fresh 
water immediately after being laid, the eggs do not hatch. Freshly 
hatched larvse die if transferred from concentrated salt water to 
perfectly fresh water, but in the case of adult larvse taken from their 
natural habitat and placed in tap water, development proceeds in a 
normal manner, but the remainder of the larval stage and the pupal 
stage are much prolonged. Some interesting observations on the habits 
of this mosquito have been recorded by Boss in a commimication to 
the Liverpool School of Tropical Medicine.* 

(a) Dwraiion of Life ofM. melitensis in Acartomyia Zammitii. 

Working on the lines already indicated, several series of Acartomyia 
were fed on inifected animals, then two or more destroyed after each 
of several intervals of time, the contents of the stomach of each plated 
out, and an enumeration made of the number of M. mdOerms developing 
and the total contents of all stomachs averaged. In the later series the 
salivary glands were dissected carefully out and plated separately, 
bat in no case was M. meliiensis isolated from this situation. During 
the intervals between the platings the infected mosquitoes were kept 
alive by suppljing them daily with fresh fruit, etc., or by regularly 
feeding them on alternate days on healthy monkeys in the attempt to 
transmit infection. 

* Bom, £. H., " On the Habits of the Marine Mosquito (Acariomyia 2iammUi%),'^ 
Beports of the Lirerpool School of Tropical Medidne, Memoir XVII^ 1906. 
(13984) g 2 



Digitized by VjOOQ IC 



84 Dr. Eyre, Major McNaught, C3apt Kennedy, and Dr. Zammit. 



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Bacteriological arid Experinuntal InvedigationSy 1906. 85 

From these preliminary investigations it will be seen that in two of 
the series where the original meal of blood from the infected guinea- 
pig contained a fairly large number of cocci, the blood present in the 
stomach of the host proved a suitable nidus for the ingested micrococci 
and that multiplication proceeded for a limited period, but by the 
fourth or fifth day at latest the micrococcus had disappeared from the 
stomach of its host, whilst examination of the salivary glands 
invariably failed to demonstrate its presence. It is interesting to note, 
and is probably explanatory of the observation, that these two series 
comprised insects that had been fed upon healthy monkeys in the 
interval between 48 and 72 hours. 

By establishing plate cultivations from the black and brownish 
droppings of the infected mosquitoes collected from the sides and 
corks of the mosquito tubes, the fate of the M. melUensis was explained, 
for the excrement was found to contain the micrococcus in large 
numbers for the few days following the feeding, and as long as any 
altered blood was being voided; as soon as the excrement regained 
its yellowish or white colour, the M. melitensis ceased to be demon- 
strable in it. The living coccus could also be recovered from excrement 
voided certainly 10 days previously. The full details of foiu" of these 
series of investigations are here inserted (see Table XXIII). 

(b) Virulence of M. melitensis after Passage through Acartomyia 

Zammitii. 

Having thus determined approximately the duration of t&e stay 
of M» melitensis in the body of the mosquito and the path by which it 
leaves the insect, experiments were made to determine whether the 
coccus undergoes any vital change as a consequence of its sojourn in 
an insect host. In the first place cultivations of -cocci, isolated from 
the mosquito stomach and from the droppings respectively, were 
employed to inoculate healthy guinea-pigs intracerebrally. 

As in each case positive results were obtained, and the animals 
succumbed from an acute M, melitensis septicaemia, further experiments 
were carried out iu which the infected blood contained in the stomachs 
of individual mosquitoes was inserted under the dura mater of the 
guinea-pig. These experiments also gave imif ormly positive results, and 
the inevitable conclusion is that the coccus undergoes no loss of 
virulence in its passage through the body of the mosquito. Details of 
some of these experiments are inserted in Table XXIV (p. 86). 

(c) Acartomyia Zammitii as the Infective Agent, 

Attention was now directed to the question of the transference of 
M. melitensis to the monkey viA Acartomyia, and for this purpose healthy 
monkeys in good condition which had been imder observation, housed 



Digitized by VjOOQ IC 



86 Dr. Eyre, Major McNaught, Capt. Kennedy, and Dr. Zammit 

Table XXIV. — ^Virulence of M. meUtensis after Passage through 

Mosquito. 



Gtdnea-pig 


Dose of 


Source of 


Method of 


Besult. 


No. 


Jf. melUentit, 


M, melitetuu. 


inoculation. 


I 


loop. 
01 1 


Culture from 
faeces of mos- 
quito in Series I, 
Table XZIU 


'Intoicranial 


*! Death in 30 hrs. 
1 from If. melu 
1 tensis septic- 


II 


0-1 J 


»» 


J flsmia. 


in 


1 


Culture from 
stomach of mos- 
quito 48 hours 
after feeding 
(Series II, Table 
XXIII) 


i> 


Death in 48 hrs. 
from M, fndi- 
tenns septio- 
tsmia. 


IV 


Contents — blood and oocci — of 


Subdural 


Death in less 




stomach of Acartomyia 48 hours 




than 24 hrs. 




^ter feeding (cf. Series 11, Table 




from Jf. mdi. 




XXIII), mixed with 01 c.c. 




tensis septic- 




normal saline solution 




aemia. 



in mosquito-proof cubicles for a considerable period, and which had 
never shown any evidence of the presence of specific agglutinins in 
their blood were selected, and transferred to separate mosquito-proof 
cubicles on the Laboratory terrace. On the morning of the day on 
which it was to be subjected to the bites of the infected mosquito, the 
back of the thighs and legs of the experimental monkey were closely 
shaved, care being taken to avoid abrading the skin. The animal was 
then returned to its cage until the commencement of the experiment. 
When all was ready the animal was brought into the laboratory and 
stretched out face downwards on a table. The shaved areas of skin 
having been washed with distilled water and dried, the mosquitoes, each 
in its separate tube, were apphed to the denuded spot and allowed to 
feed. This was often a tedious process and required some hours for 
its completion, and when using Acartomyia the feeding was often 
prolonged until after midnight; still, given adequate assistance in 
securing the monkey, as many as four of the mosquito-tubes could be 
manipulated by one worker. 

In these experiments the process of feeding was carefully watched — 
to beguile the tedium of waiting as much as to ascertain the moment 
of repletion — and is here briefly described on account of the important 
bearing one feature of the process has upon the question of the infec- 
tion of man through the agency of this insect. The mosquito having 
decided to feed, settles down at the gauze covered end of the tube, and 
after a few preliminary investigations with its proboscis, determines on 



Digitized by VjOOQ IC 



Rideriological and JSji'permiental Invedigatioiis, 1906. 87 

the point of skin to be punctured. Next the head and proboscis are 
lowered, while the body remains more or less horizontal. Then the 
hind pair of legs are raised to the level of the posterior part of the 
abdomen, and employed in massaging the abdomen by a series of 
stroking movements passing from the thorax towards the anus. These 
movements often, but not invariably, result in the extrusion of some 
of the intestinal contents which, in the case of insects previously fed 
on mammals, is easily recognisable by reason of its colour. This small 
mass of excrement drops either on to the gauze covering the tubes, or 
where the meshes are \^de, actually on to the skin of the animal upon 
which the mosquito is feeding. In the meantime the abdomen of the 
insect has become distended with blood, and as soon as the mosquito 
has completed its meal the proboscis is withdrawn, stroked and cleaned 
by the help of the anterior pair of legs, and then the insect flies up to 
the upper part of the tube and settles down in a resting position. 
This sequence of events holds good in the case of other blood-sucking 
species of mosquito as well as Acartomyia. 

Leaving now, for a moment, the region of observed facts for a short 
incursion into the realms of theory, it appears highly probable that 
a mosquito having fed on a case of Malta Fever in the acute 
septicaemic stage whose blood contained large numbers of the cocci, 
might, 48 hours later, settle upon a healthy individual and proceed to 
insert its proboscis into the skin. Massaging its abdomen, the mosquito 
then deposits a mass of bloody excrement, enclosing the coccus in 
a virulent condition, upon the surface of the skin, a few millimetres 
distant from the puncture made by its proboscis. The bitten 
individual, now alive to the fact that a mosquito is feeding upon him, 
rouses himself, frightens off the mosquito or kills it in situ^ and 
promptly proceeds to thoroughly scratch the infective excrement into 
the site of the minute wound and, following a successful inoculation, 
an attack of Malta Fever ensues. Such a sequence of events is well 
within the range of possibility, and yet the necessary combination of 
factors is sufficiently uncommon to render this method of infection as 
rare as the experiments upon monkeys would indicate. 

To return to the actual experiments — after feeding a number of 
infected mosquitoes upon the monkey, the animal was returned to its 
cubicle and carefully observed from day to day until some four to 
€dx weeks had elapsed, when the animal was killed and carefully 
examined post-nwrtem. 

Of the experiments carried out with the aid of Acartomyia Zammitii, 
bat one monkey was infected, and in this case the infection was an 
extremely mild one. The history of this experiment is as follows : — 

Normal Monkey No. 175 was bitten, late at night, by six Acarto- 
myia, which had fed between 48 and 50 hours before on Guinea-pig 
No. 71 (which succumbed to M, nielitensis septicaemia 10 hours after 

Digitized by VjOOQ IC 



88 Dr. Eyre, Major McNauglit, Capt. Kennedy, and Dr. Zammit. 

intracerebral inoculation, and the heart blood at the post-mortein 
examination was found to be absolutely teeming with the micrococci). 
The stomach contents of some of the mosquitoes, plated immediately 
after the tei-mination of the feeding, yielded plates in which the 
colonies of M. meliUnsui were so numerous as to be absolutely xmcount- 
able. The bitten monkey was subsequently, kept in a mosquito-proof 
cubicle, and every precaution which experience could suggest was 
taken to avoid any chance of accidental infection. The serum was 
tested on alternate days for the presence of M. melitensis agglutinins, 
and on the 11th day gave a positive reaction "in dilution of 1 in 20. 
The serum value rose gradually, and on the 15th day had reacted 
1 in 80, while an incomplete reaction was given with a dilution of 
1 in 100. On the 21st day no reaction could be obtained, even with 
1 in 10 dilutions, therefore the animal was killed. During the period 
of three weeks, in which the monkey was imder observ^ation, the 
temperature chart, which is here inserted, gave no indication whatever 
of a successful subcutaneous inoculation. 



Chart 10. 

At the post-mwiem examination the spleen was found to be slightly 
enlarged, and all the superficial glands were markedly enlarged' and 
congested. 

In none of the plate cultivations prepared from heart blood, spleen 
pulp, and axillary and inguinal glands could M, melitensis be detected, 
but in one of the three tube cultures prepared from spleen pulp twa 
colonies appeared of a minute coccus, which when tested against 
specific serum became agglutinated, although in a somewhat atypical 
manner. Subcultivations were prepared from these, and further 
investigation proved that one of the two colonies was composed of 
genuine M, melitensis. 

In none of the other monkeys did the serum at any time during the 
period of observation contain specific agglutinins, nor could the 
presence of M. mditenm be detected in the blood. Finally, at the 
post-mortem examination M. melitensis was never recovered from any of 
the other organs or tissues. 

Before tabulating the results of those of the Acartomyia experi- 
ments in which the value of each factor was accurately known, it may 
be useful to recapitulate the exact method of procedure — a reiteratioa 
which the importance of the subject alone condones : — 



Digitized by VjOOQ IC 



Bactcrioloyical and Experimental Investigations, 1906. 89' 

(a) First a healthy guinea-pig was inoculated intracerebraUy with 
a sufficient dose of highly-virulent culture of M, meliteitsis to produce 
such an acute infection that in the course of a few hours large numbers 
of the cocci would be present in the peripheral blood. 

(6) Next, when the temperature of the inoculated guinea-pig had 
reached 105° F. or 106** F. (a point which previous experience had 
shown corresponded to rapid multiplication of cocci in the blood), the 
first feeding of the mosquitoes was commenced. 

(c) Several female mosquitoes — the number varying with the 
experiment from 20 to 70 — each enclosed in a separate feeding tube, 
were applied one by one to a bare patch of skin between the infected 
guinea-pig's shoulders and encouraged to bite. As soon as one 
mosquito was seen to be full of blood, and to have settled to repose in 
another part of the tube, the tube was taken away, marked with its 
serial number, the number of the guinea-pig, and the date and time of 
feeding, and replaced by the next tube containing a fasting mosquito. 

((f) During the progress of the feeding experiment, or immediately 
after its termination, some of the mosquitoes (the number varying in 
each experiment with the number of mosquitoes that had fed and 
were available) were killed with ether vapour, and the contents of the 
stomach plated out to determine the average number of cocci ingested 
with the blood of the guinea-pig. The feeding tubes containing the 
remainder of what may now, for purpose of reference, be termed 
" infected mosquitoes " were placed in te8t-tul>e racks and put on one 
side. 

(e) Forty-eight hours after the primary feeding of the mosquito 
a healthy monkey was selected, stretched face downwards on a table, 
and the back of the fleshy part of each thigh and leg shaved, great 
care being taken to avoid cutting or grazing (this process was often 
carried out some hours earlier in the day). The shaved areas were 
washed with distilled water and partly dried with sterile wool. 

(/) Each of the infected mosquitoes was now applied in turn to- 
the shaved area, and allowed to bite the monkey and fill itself with 
blood. Some of course refused ; these were put aside for feeding at 
72 hours. 

{g) At the termination of the feeding on the monkey two or three 
of the infected mosquitoes that had filled themselves were plated out 
to determine whether the contents of their stomachs still contained 
the M. melitensis, and to prove beyond question that the mosquitoes 
that bit the experimental animal actually contained infective material 
at the moment they were engaged in feeding on the monkey. 

(A) At 72 hours after the primary feeding such infected mosquitoes 
as had refused to bite the first monkey (at 48 hours) and were still 
living, were applied to a second healthy monkey, and if they bit and 
filled themselves with blood the same routine was repeated. 



Digitized by VjOOQ IC 



90 Dr. Eyre, Major McNatight, Capt. Kennedy, and Dr. Zammit. 



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Bacteinolof/icfil and Erpai mental Invcdigatiom, 1906. 91 

(i) At 96 hours after the primary feeding the infected mosquitoes 
(diminished in number as a result of death from natural causes or 
destruction for plating purposes) were applied to a third, and so on as 
long as any of the mosquitoes remained alive. 

(j) The monkeys after being bitten were placed in mosquito-proof 
cubicles, and observed from day to day as to temperature and general 
condition, blood reactions, etc., until the termination of the experiment, 
when a careful post-mortem examination was carried out. 

It was usual not possible to carry the above scheme beyond the 
^6 hours, owing to the death of the infected mosquitoes, as will be seen 
in Table XXV. 

5. Expenments with Stegomyia fasciata. 

Having dealt at some length with those mosquito experiments in 
which Acartmnyia Zammitii was the species employed, those in which 
Stegomyia fasciata was employed as the infective agent may be briefly 
dismissed, for the technique was identical in both series of experiments. 

(a) Duration of Life of M. melitensis in Stegomyia fasciata. — Experi- 
ments were made to determine the duration of life of M. melitensis in 
the stomach and intestines of Stegomyia in the manner already 
described (vide pp. 81 and 82), and the results obtained were very 
similar, for it was found that the micrococcus could rarely be recovered 
from this mosquito beyond four days after the primary feeding on the 
infected guinea-pig. The results of a few representative experiments 
are given below in Table XXVI : — 



Table XXVI. — Stegomyia fasdaia as the Host of M. melitensis. 






Interral 


Number of 


ATerage 


No. of 


Source of 


between 


mosquitoes 


number of 


series. 


infection. 


feeding and 


dissected and 


M. mditentit 






dissection. 


plated. 


per stomach. 


I 


Ouinea-pig No. 140 


24 hours 


2 


00 






48 „ 


2 


6177 






72 „ 


3 


• 






84 „ 


2 


nil 


n 


Guinea-pig No. 150 


80 minutes 


3 


00 






48 hours 


3 


44 






»6 „ 


2 


nU 


ni 


Guinea-pig No. 151 


2 hours 


1 


00 






24 „ 


2 


44 






48 „ 


2 


5 






7« .. 


2 


• 






96 „ 


8 


nil 



00 s innumerable. 
* M, meUletms present, but plate unworkable owing to contamination with 
•aproj^Ttes probablj derired from exterior surface of mosquito's abdomen. 



Digitized by VjOOQ IC 



92 Dr. Eyre, Major McNaught, Capt. Kennedy, and Dr. Zammit. 

(b) Stegomyia fasciata as the Infective Agent. — The experiments in 
which the attempt was made to transmit M, melitensis from the infected 
guinea-pig to the healthy monkey vid Stegomyia fasctatOy were planned 
and carried out in a manner identical with those detailed in connection 
with Acartomyia Zammitii {vide p. 86), consequently the technique 
need not again be described. The only point to be noted is that, as- 
the solitary infection produced when Acartomyia was employed as the 
infective agent ensued when the mosquitoes bit a healthy monkey 
48 hours after the primary feeding on the infected guinea-pig, the 
majority of the Stegomyia experiments were performed at that 
interval. 

The possibility that infection might be produced as the result of 
puncturing the skin of the healthy subject by the soiled proboscis of a 
mosquito that had partly filled itself from an infected patient, was 
tested experimentally in one instance only, but in that single instance — 
as events subsequently proved — the conditions were exceptionally 
favourable to the transmission of the specific virus. The details of this- 
experiment were as follows : — 

One female Stegomyia, in its feeding tube, was applied to the back 
of an infected guinea-pig (prepared for the experiment by intracranial 
inoculation of M, melitensis 8^ hours previously) and allowed to settle 
down, insert its proboscis into the skin, and commence to feed. The 
instant that blood could be distinguished entering its abdomen, the 
feeding tube was removed and applied to the shaven leg — immediately 
over the external saphenous vein of Monkey No. 236, and the mosquito- 
allowed to bite and complete its meaL Within half an hour of ita 
removal from the monkey, the contents of this mosquito's stomach were 
plated out, but none of the plates that were prepared showed a single 
colony of M, melitends. 

Immediately the first mosquito had completed its meal, a second 
Stegomjria was applied to the guinea-pig and allowed to bite and about 
half fill its abdomen with blood. It was then transferred to the same 
monkey and applied, again over the external saphenous vein, at a point 
a centimetre or so above the first puncture. The mosquito settled down 
at once, inserted its proboscis, and proceeded to fill itself up with the 
monkey's blood. A short time after the mosquito had completed ita 
meal, it was killed and the contents of its stomach plated out. Subse- 
quent enumeration of the colonies of if. melitensis that developed on 
the plates showed that the stomach of this mosquito contained about 
5000 co|ci. 

Following the feeding of the second mosquito, a third Stegomyia 
was half fed on the same infected guinea-pig and then transferred to- 
the monkey and allowed to bite over the vein, just between the first 
and second mosquito bites, and complete its meal. All the plate 
cultivations prepared from the stomach contents of this third mosquito 



Digitized by VjOOQ IC 



Bacteriological and BoaperimerUal Investigations, 1906. 93 



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94 Dr. Eyre, Major McNaught, Capt. Kennedy, and Dr. Zammit. 

yielded pure growth of M, mditemL% in which the colonies were so 
numerous as to be absolutely uncountable. 

The monkey that had been bitten by these three mosquitoes, 
however, remained perfectly healthy, specific agglutinins remained 
absent from its blood, and, when killed and examined post mortem 
46 days later, showed no signs of infection with M. melUensis. 

Two of the three mosquitoes, therefore, that first sucked blood from 
an infected guinea-pig and then finished their meal upon blood 
abstracted from a healthy monkey were conclusively shown to have 
taken up with the guinea-pig's blood a very large number of the 
micrococcus and, one would infer, had had ample opportunity of soiling 
the proboscis in each case, yet the monkey remained uninfected. 

Details of the experiments in which the various data were accurately^ 
ascertained are tabulated below; other similar experiments were 
performed, but, owing to failiure of plate cultures and other causes,, 
there was no evidence as to the numbers, or, indeed, the presence of 
M. melitensis, in the interior of the mosquitoes used for biting. Sueh 
experiments being worthless, are not included in the results pre- 
sented in Table XXVII. 

The net result of the mosquito experiments may now be summarised 
very briefly. Out of 14 experimental monkeys bitten imder conditions 
which have been accurately recorded (and disregarding a fiuther six, 
where the necessary data are missing in whole or in part, but in none of 
which did infection occur), one monkey alone has given evidence of actual 
infection. In this one positive case, the M, nuJiteims contained in the 
stomach of the mosquito at the time it bit the monkey — 48 hours after 
the primary feeding on the infected guinea-pig — ^were innumerable in 
quantity, and the inference is justifiable that, if excrement was dropped 
on the skin while feeding on the monkey, nimierous living and virulent 
M. melitenm must have been present therein. Consequently, after 
removal from the operating table there was nothing to prevent this 
monkey (or, indeed, any of the experimental monkejrs) scratching the- 
infective material into the punctin*e, and this is quite possibly a case 
in which some such variety of infection occurred. 

6. Experimmts loith oilier Species of Ma^uiioes, 

(a) TheobcUdia spathipaXpis, — The opinion has been freely expressed 
in some quarters that the members of this species are fruit feeders only, 
and never suck blood. This statement, however, does not hold good 
for Malta, as, during the summers of 1905 and 1906, whilst examining 
specimens of mosquitoes captured in various parts of the Island,. 
Theobaldia was sometimes noted gorged with blood. One of the 
members of the Commission received several specimens in the course 
of the winter of 1905 — 1906, which had been "caught feeding" on 
the human subject, one of which had so recently fed that the blood 



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Bdcteriological and ExperiTnental Investigations, 1906. 95 

cells were unaltered and could readily be demonstrated microscopically. 
This particular specimen was submitted to Mr. E. E. Austen for con- 
firmation of identity, and his reply is here inserted : — 

Copy of letter from Mr, E, E, Austen, 

British Museum (Nat. Hist.), 
Cromwell Road, 

London, S.W., 

10/A January, 1906. 
Dear Sir, 

I am very sorry that your letter of December 9th, enclosing a 
specimen of Theobaldia (Cviex) spathipalpis, has remained so long 
unacknowledged. The letter arrived here while I was absent on a 
month's vacation, and since I have only just returned to duty, it was 
consequently impossible for me to reply sooner. Please forgive the 
delay. 

Your identification of the species is perfectly correct, and the notes 
in your letter on its occurrence and bloodnsucking habits in Malta are 
very interesting. I see you say that " it is described by Giles and 
Theobald as non-blood-sucking," but if you look at Theobald's mono- 
graph, vol. i, p. 341, you will see that the species is stated (apparently 
on the authority of Major Birt) to be "troublesome" in Gibraltar; 
it would appear, however, from the following page that Ficalni believes 
the species to be a vegetable feeder, and Grabham, writing with 
reference to Madeira in Theobald's monograph, vol. iii, p. 155, says 
" the people told me they had never observed this form attacking man 
or animals. They fed eagerly on banana slices, but never attempted 
to bite my hands." 

It would be remarkable if Theobaldia spathipalpis should prove to be 
exclusively vegetarian in some localities, but a blood-sucker in others. 

Believe me. 

Yours very truly, 
(Signed) E. K Austen. 
Captain J. Crawford Kennedy, 
RA.M.C. 

In view of these observations, numerous attempts were made ta 
induce female Theobaldia, some captured and others bred in captivity,, 
to bite infected guinea-pigs, but with negative results. Neither could 
they be persuaded to bite either monkeys or man. 

(b) Cidex fatigans and Culex pipiens, — For all practical purposes these 
two species are identical, and in breeding out in the Laboratory na 
attempt was made to differentiate between them. 

Very few experiments were made with these mosquitoes, as it waa 

Digitized by VjOOQ IC 



"96 Dr. Eyre, Major McNaiight, Capt. Kennedy, and Dr. Zammit. 

a matter of the greatest difficulty to induce them to feed on the 
guinea-pig in the first instance, or on the monkey in the second. 
Further, whilst on the one hand no infection resulted, on the other 
no proof of the infective character of the mosquito was forthcoming, 
as plate cultivations of the stomach contents were omitted — conse- 
•quently the experiments referred to were worthless. 

(c) Anopheles mactdipennis. — No experiments were made with this 
mosquito, as its only breeding place is situated in a small, almost 
uninhabited valley in the centre of the island, and the imagines are 
not met with elsewhere than in its immediate vicinity. It is therefore 
obvious that this mosquito can have next to nothing to do with the 
•dissemination of M. melUenm, 

7. Biting Flies — Stomoxys calcitrans. 

Although the experiments of Edmond and Etienne Sergent* have 
shown that Stomoxys does not usually act as the infective agent con- 
•cemed in the transmission of the trypanosome of North African camel 
disease, the fact that one successful infection in the rat was pro- 
■duced through the medium of this fly, encouraged the hope that in 
the case of such a minute coccus as M. meWeriMs success might attend 
•experiments in the direction of transmission of the micrococcus to the 
;goat by means of this biting fly. 

(a) Duration of Life of M. melitensis in Stomoxys calcitrans. — As in 
the case of the mosquito, an inquiry was first made into the ability of 
Stomoxys to act as the host to J/, melitensis, and the experiments were 
conducted on identical lines. Abundant supplies of Stonioxys were readily 
obtained from stables, so that it was unnecessary to breed them. When 
<japtured they were placed in a fair-sized gauze-covered cage, brought 
up to the Laboratory, and, as the insects were for the most part 
'Caught whilst feeding on the horses or mules, they were usually kept 
for a day before using to enable them to dispose of the blood with 
which they were filled. They were then transferred singly to feeding- 
tubes similar to those used for mosquitoes. 

A guinea-pig was then infected, and when its blood was crowded 
with the micrococci, flies, each enclosed in a feeding-tube, were 
applied in turn to an area of skin denuded of hair and allowed to fill 
themselves with blood. 

It was soon found that the wastage from death was excessive unless 
these insects were fed every 24 hours ; this necessitated feeding the 
balance left over after every plating period on a healthy guinea-pig 
«very day, but even this plan did not entirely prevent the heavy 
mortality. 

At varying intervals several flies were killed by ether vapour, dis- 

• 'Annales del'Institut Pasteur,' toI. 19, 1905, pp. 16 et »eq. 



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B(vcteriologic(d avd ExperimeifUal InvestigatioTis, 1906. 97 

sectecl, the contents of the stomach and intestines plated out, and the 
resulting colonies of M. melitensis enumerated. 

Plate cultivations were also established from the droppings, and it 
was found that, as in the mosquito, the excrement contained numerous 
living M. melitensis for many hours after feeding upon the infected 
guinea-pig. 

In the following table the results of a number of these experiments 
are arranged, and from that it will be seen that although the micro- 
coccus has sometimes disappeared entirely from the alimentary tract 
within a couple of days, it may persist even up to five days. 



Table XKYni.—Stomoxi/8 ealcikwis as 


the Host of if. mdiUnsis. 


No. of 
series. 


Source of 
infection. 


Interral 

between 

primary 

feeding and 

dissection. 


Number of 

Stomoxjs 

dissected and 

plated. 


Ayerage 
number of 

per stomach 
and intestines. 


I 


Guinea-pig No. 72 


16 hours 
24 ,, 
86 ., 
60 „ 


1 
1 
I 
6 


197 

nU 

19 

136 


II 


Ghiinea-pig No. 82 


15 minutes 
24 hours 
48 „ 
72 „ 
96 „ 


2 

1 
1 
1 
1 


882 
5 

nil 
nU 
nil 


III 


Ghuneft-pig No. Ill 


15 minutes 
18 hours 
40 „ 
»7 „ 


2 
2 
2 
2 


847 

17 

5 

2 


IV 


Ouinea-pig No. 122 


15 minutes 
24 hours 

£ : 

100 „ 


5 
8 
3 
8 
8 


2,248 
nil 
nil 
nil 
400 


V 


€h2ine»-pig No. 150 


2 hours 
90 „ 


3 
2 


912 

nU 


VI 


6hiine».pig No. 162 


1 hour 
48 hours 
120 „ 


2 
2 
6 


3300 
nil 
50,852 



(b) Stomoxys calcitrans as the Infective Agent. — The experiments in 
which infected Stomoxys were allowed to bite healthy animals were 
conducted on similar lines to the corresponding experiments with 
mosquitoes. Two points of difference only need noting. 

In the first place, the kid which previous experiments had shown (vide 
(13984) A 



Digitized by VjOOQ IC 



98 Dr. Eyre, Major McNaught, Cape. Kennedy, and Dr. Zainmit 



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Bacteriological and Experimental InvestigationSy 1906. 99 

pp. 30 and 34) was extremely susceptible to subcutaneous and cutaneous 
inoculation, replaced the monkey as the experimental animal ; and in 
the second place the infected Stomoxys were fed upon the healthy 
guinea-pig in the intervals between feeding on the kid. The results 
may be very briefly stated. In all, seven experiments were carried 
out, and in no case did infection of the kid with M. melitensis ensue, 
although in one of the experiments a kid was bitten by three separate 
batches of six, five, and six Stomoxys respectively during a period of 
24 hoiu^, at intervals of 96, 102, and 120 hours after the primary 
feeding on the infpcted guinea-pig. The details of these experiments 
are arranged in tabular form under the same headings as those used 
for the corresponding mosquito experiments on pp. 90 and 93. 

8. Fleas and Bugs, 

The experiments carried out with blood-sucking Hemiptera and 
Aphaniptera were few in number and of very questionable value, even 
when considered in relation to the negative evidence they produced, 
and may be very briefly dismissed. 

Hemiptera — Cimex lectvlaria, — In view of the suggested association 
between certain cases of Malta Fever and venereal disease referred to 
by Kennedy* and the possibility of the infective virus being conveyed 
by domestic vermin, some 50 ordinary bed bugs were collected from 
low class brothels in the vicinity of the Camerata, Valletta, conveyed 
to the Laboratory and there killed and dissected. The stomach 
contents of each were then plated out in turn, but M. melitensis was 
never detected in, or isolated from, this situation. These were the only 
observations made with this parasite. 

Aphaniptera (a) Pulex irritcms. — No observations were made upon 
the human flea. 

(b) Pidex serraticeps, — Dog fleas to the number of six were collected 
from a dog (which had been experimentally infected with M, melitensis 
by subcutaneous inoculation), killed, dissected, and plated, but no 
evidence could be obtained to show that they harboured the micro- 
coccus. 

(c) Pulex scuirarum. — Again 14 rat fleas were obtained from various 
rats which had been experimentally infected with M, melitensis, and in 
whose blood M. melitensis was swarming. After being similarly 
dissected the plate cultivations established from the stomach contents 
likewise failed in every case to show the presence of the coccus. 

Two experiments were made in an endeavour to transmit 
M. melitensis from infected to healthy dogs through the agency of 
the flea : — 

1. A healthy black terrier dog was inoculated subcutaneously 

• Kennedy, * Journ. Boyal Army Med. Corps.,' vol. 4, 1905, p. 634. 
(13984) h 2 



Digitized by VjOOQ IC 



100 Dr. Eyre, Major McNaught, Capt. Kennedy, and Dr. Zammit. 

behind the shoulder with emulsion containing the growth from three 
agar tubes of M. melUensis, Three weeks later the animal, which had 
in the interval shown definite signs of infection, was killed with 
chloroform vapour and the dead body placed close to, but not in 
contact with a bitch of the same variety for a period of 24 hours, in 
the hope that infected fleas would pass from the dead body as it cooled 
to the warm body of the living animal and so transmit the infection. 
M. meliiensis, however, was only isolated post mortem from the inguinal 
and mesenteric glands of the terrier dog — not from the blood. The 
bitch never showed any sign of infection during an observation period 
of two weeks, and at the end of this time the second experiment was 
proceeded with. 

2. Another black terrier dog which had been inoculated with 
a similar dose of M. melUensis six weeks previously, and like the first 
dog had given definite evidence of infection, was killed and placed 
alongside the same terrier bitch that had been utilised for the first 
experiment, for about 14 hours — precautions being taken to prevent 
contact of the healthy bitch with either carcase or excrement of the 
infected animal This second dog when examined post mortem gave 
evidence of the presence of M. melUensis in spleen, inguinal and 
axillary glands, but the coccus was again absent from the blood. 

The bitch never showed any signs of infection. 

These two experiments are of course valueless from the scientific 
point of view, as the evidence available points to the absence of 
micrococci from the blood of the infected animal at the time of death, 
even supposing the dog fleas travelled from the carcase to the body of 
the living bitch. 

Some further experiments were then made on somewhat similar 
lines with the rat flea. The rat had always been considered by the 
early workers with M. mdiiensis as insusceptible to infection with 
this organism, but it was observed by one of the members of the 
Commission that the rat, after intracranial inoculation, dies from acute 
septicaemia in about 24 hours, the micrococcus being present in the 
blood in enormous numbers for at least the last 12 hours of life; 
while after a few intracranial passages the coccus becomes exalted in 
virulence for this particular animal and readily produces an acute 
septicaemia after either intraperitoneal or subcutaneous inoculation. 
Consequently in investigating the probability of the transmission of 
M. melUensis from the infected to the healthy rat, these highly virulent 
cultures were utilised. 

In arranging these experiments, long rat cages were selected and 
divided into three compartments, a fair-sized one at either end, and 
a small narrow one in the centre, by means of two wire-netting 
partitions placed about 6 cm. apart. The meshes of the wire netting 
forming the partitions were about 0*5 cm. in diameter. 



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Bacteriological and Eaipainiental Invest igatiom, 1906. 101 

A couple of infected white rats were placed in on6 end compart- 
ment and two healthy rats in the other ; all four rats were infested 
with large and vigorous fleas. The cage was then placed in a large 
rectangular zinc tray filled with lysol solution almost to the level of 
the floor of the cage. In the first experiment the infected rats died 
within 18 hours, and on the morning following the commencement of 
the experiment it was found that the other two rats had partly broken 
down the partitions and were occupying the same compartment as the 
dead rats. 

The infected animals examined post mortem were noted to be quite 
free from fleas. The blood of each was crowded with the micrococci, 
as were spleen, kidneys, and all other organs. 

The healthy rats died six hours after the infected animals, and at 
the pod-martem examination, which was conducted at once, no fleas 
could be found on the carcases, although shortly before death the 
animals were simply swarming with them. Many dead fleas were, 
however, found in the lysol moat surrounding the cage. From the 
pod-mariem examination no evidence of infection could be obtained, as 
M. melUensis could not be detected in, or isolated from any of the 
tissues or organs. 

This experiment was repeated a fortnight later in precisely the 
same manner. 

Again the infected rats soon succumbed — one within nine hours, its 
companion within 22 hours after inoculation. No fleas could be 
detected on the carcases and no dead fleas were present in the lysol. 
Post-mortem blood and organs were crowded with micrococci. 

The healthy rats were killed with chloroform seven days later and 
examined at once. Specific agglutinins were absent from the blood of 
each. Plate cultures from the blood and various organs failed to show 
any colonies of M. mslitensis^ neither could the micrococcus be detected 
in the bodies of the fleas caught on the bodies of these rats. 

In both these experiments the M, melitensis was undoubtedly present 
in the infected rats, and the fleas upon them in all probability absorbed 
the coed with the blood of their hosts. Further, it is a matter of 
common knowledge that fleas forsake the bodies of dead or dying 
rats for healthy living members of the same species, and in these 
experiments should have had ample opportunity of biting the healthy 
rats in the further compartment. Yet in neither of the four rats 
exposed to bites from presumably infected fleas did infection with 
M, mdiiensis ensue and the results were absolutely negative. 

V. — Naturally Acquired Infection {M. meliteima) in Various 

Animals. 

During 1905 numerous observations were carried out upon various 
animals during life to determine whether infection with M. melitensis 



Digitized by VjOOQ IC 



102 Dr. Eyre, Major McNaught, Capt. Kennedy, and Dr. Zammit. 

occurred naturally. These obseryations were usually limited to an 
examination of the blood for M. melitensis agglutinins, but were followed 
in a few cases by post-mortem examination. As a result of these exami- 
nations, it was clearly shown that cows and dogs living in the Island 
acquired naturally an infection with M. mdiUnmy while from the 
presence of positive serum reactions in low dilutions, it was suggested 
that mules were also susceptible to the pathogenic action of the coccus. 

Similar observations were continued during the summer of 1906, as 
many various species of animals being examined as opportunity per- 
mitted, and the results noted are here recorded. 

1. Rats* — The close association of epizootic plague in the rat and 
epidemic plague in man suggested the possibility of a similar asso- 
ciation between the rat and Malta Fever, but inquiry amongst residents 
in the Island failed to support this view. 

Arrangements were then made for the supply of sewer rats from the 
dockyard and from the Valletta sewers for examination in the 
Laboratory. Owing, however, to the frequent and prolonged absence 
of the Fleet from Malta, the nimiber of rats obtainable from the dock- 
yard was small ; it also proved a matter of greater difficulty to obtain 
the rodents from the Valletta sewers, even a capitation fee of M. per 
head failing to secure the necessary material, so that a total of 84 rats 
examined during the months of May, June, and August is all that could 
be obtained. During May and June, the rats on arrival at the 
Laboratory were sorted out into cages and numbered, and blood 
collected from each to afford serum for the agglutination reaction, 
and also for planting out for the recovery of M. melitensis^ and it was 
intended that a complete post-mjortem examination should be made only 
when specific agglutinins were detected in the blood. 

Table XXX. — Examination of Sewer Rats. 



Month, 1906. 


Number of 
rate examined. 


Serum 
reaction. 


M, melUennt in 


Blood 


Other organs. 


May 


72 


Abeent 
>» 

Abeent 


Absent 
>» 

Absent 


Not examined. 

»t 

Absent 


June 

July 

August 


6 


8 



In July no sewer rats at all could be obtained, but during that 

month experiments were carried out which showed that while the rat 

was susceptible to infection with the micrococcus, agglutinins were not 

usually formed during the course of the disease, and consequently a 

* Compare these Reports, Y, p. 40. 



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Bacteriological aiid jEayperimerUcU InvestiffotioTis, 1906. 103 

complete post-mortem was performed on the eight rats that were 
available during August. 

The results of these examinations were completely negative. 
None of the specimens of rat blood that were examined yielded an 
agglutination reaction even in low dilutions, and M. melUensis was never 
recovered from blood or organs. 

Several dozen white rats, bred on the Island and purchased for 
experimental work, were also tested before use as to the presence of 
the serum reaction to M. mditensis, likewise with negative results. 

2. Dogs* — ^Forty-six stray dogs were examined between the beginning 
of March and the end ol August for the presence of M. melitensisy and 
of theafe ikrae yielded a positive reaction— one in dilution of 1 in 10, 
one in dilution of 1 in 20, and a third in all dilutions up to 1 in 100. 
Although a reaction obtained in a dilution of 1 in 20 is by no means 
absolute or even satisfactory evidence of infection, all three of these 
animak were killed and examined post mortem^ but M. melitensis was 
never i^ecovered from any of the organs or tissues. 

Table XXXI. — Examination of Stray Dogs. 



Month. 


Number of 
dogs examined. 


Serum 


M. melUensit in 


Blood. 


Other tissues 
and organs. 


liarch 


10 

13 



o 



23 


1 X 1 in 10 
Absent 

1 X 1 in 20 
1 X 1 in 100 


Not examined 
it 

»» 

Absent 


Not examined. 
» 
»» 
»> 
>» 
Absent 


ADril 


Ma7.:..: 


June 


July 


" ***/ 

Aogost 



3. Qmnea-pigs. — The numerous guinea-pigs employed in the experi- 
mental work were all bred on the Island, and as a preliminary pre- 
caution the blood was carefully examined in many different dilutions 
with reference to the presence of specific agglutinins. These substances, 
however, were invariably absent from the blood. 

4. Mules* — Some mules were imported into Malta from Sicily at the 
beginning of 1906. * Steps were taken to examine their blood as soon 
as posfflble after arrival As a result of this examination the blood 
from each of these mules yielded a partial or incomplete reaction with 
serum in low dilution (1 in 10), but no reaction whatever could be 
obtained in higher dilutions. 

Six months later the blood from these same nine mules was again 

* Compare these Beports, XII, p. 86 9t seq. 



Digitized by VjOOQ IC 



104 Dr. Eyre, Major McNaught, Capt. Kennedy, and Dr. Zammit. 



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Bdderiological and Experiimervtai Investigations, 1906. 105 

examined, with the result that one reacted well and one incompletely 
in dilation of 1 in 500 ; two others reacted, one completely and one 
incompletely in dilutions of 1 in 200. The serum reactions of the 
remaining mules remained practically unaltered. 

Judging these results from the alteration in their serum values, it is 
practically safe to assume that two of the mules (Nos. 48,401 and 
48,404) had acquired M. meliiensis infection during the course of their 
first summer in Malta, and probably Nos. 48,396 and 48,403 had also 
becmne infected. The absence of any serious sickness in these animals 
needs no comment in view of the lack of constitutional symptoms in 
the infected goats. Unfortunately, posl-mortem examination of these 
animals was not possible. The results of these examinations are given 
in Table XXXH. 

5. Horses, — In order to obtain some idea as to the prevalence of 
M. meliiensis infection in the horse — as judged by the serum reaction 
standard — samples of blood from 100 horses attached to the Moimted 
Infantry camp at Ghain Tuffeiha were examined. 

The results obtained were as follows : — 

Negative reaction 54 

{Incomplete reaction in 1 in 10 dilution 14 

Complete „ „ „ 11 

11 



{Incomplete „ 1 in 20 

Complete „ „ 

{Incomplete „ 1 in 50 

Complete „ „ 



7 
2 

1 

100 



It wiU thus be seen that the agglutination reaction was obtained in 
varying dilutions in 46, the test proving absolutely negative in 54. 
In 14 of those animals yielding a reaction of some sort, the result of 
the test was "incomplete," clumping with 1 in 10 dilutions, and as 
such a reaction is valueless as evidence of infection, these animals may 
be disregarded. Again, neither a complete reaction in a dilution of 
1 in 10, nor an incomplete reaction in dilution of 1 in 20 can 
be regarded as incontrovertible evidence, and at any rate, in the 
case of the human subject, neither would be accepted as deciding 
a question of diagnosis. Eliminating such animals as did not give a 
positive reaction in at least as high a dilution as 1 in 20 — ^and even 
this standard is open to question — 10 animals are left which show signs 
of infection by Jf. melitensis, three, indeed, in a marked manner. 
Unfortunately, no further examination of these infected animals was 



One of the aoimals (No. 95) was subsequently shot, and examined 
pod mortem. During life the titre of its serum, when tested against 



Digitized by VjOOQ IC 



106 Dr. Eyre, Major McNaught, Capt. Eennedj, and Dr. Zaminit. 
Table XXXIII. — Examination of Horses. 



Serial No. 



8 
25 
27 
42 

98 
113 
U7 
111* 
120 
126 
126 
138 
140 

146 

2 

28 

30 

43 

72 

75 

96 

103 

114 

130 

137 

9 
18 
22 
56 
58 
69 
61 
70 
82 
91 
127 

37 

38 

66 

71 

115 

129 

148 

64 

74 

94 



Seiricein 
Malte. 



A^lutiiut. 
tion value 
of serum. 



FreTious medical 
history. 



2 years 

6 „ 

5 „ 

6 „ 



5 jears 

5 V, 



2 „ 
1 year 
4 years 

1 year 

6 years 



5 months 

6 years 

5 months 

5 „ 

6 years 
6 „ 
6 „ 
6 ., 
6 ,. 

5 „ 

6 :, 

« » 

6 „ 

6 „ 

2 „ 

6 „ 

6 „ 

6 „ 

6 „ 

1 year 

2 years 
6 „ 



^1:10±^ 



i- 1 : 10 + 



}'l:20 ±^ 



- 1:20 +^ 



I 1 :60db|| 



1:60 + 



NQ 

One attack oolic 

NU 

Two attacks colic: one 

attack catarrh 
NQ 



Present 
conditioD. 



One attack catarrh 

Nii^ 

im 

Nil 

Nil 

NU 

Two attacks colic: one 

attack horse-pox 
One attack dial>etee 



One attack stomatitis . 

Nil 

Two attacks colic 

NU 

One attack catarrh . . . . 

NU 

NU 

NU 

NU 

NU 

NU 



NU 

One attack catarrh ... 

NU 

NU 

NU 

NU 

One attack straoeles 

NU „ 

NU 

One attack catarrh ... 
One attack catarrh ... 



One attack pink eye.. 

NU 

NU 

NU 

Two attacks catarrh 
Two attacks debility 
NU 



NU. 
NU. 

NU. 



Good 
Good 
Good 
Good 

Good 

Good 

Oood 

Ot)od 

Fair 

Good 

Good 

Good 

Poor 

Fair 

Good 

Fair 

Good 

Fair 

Good 

Good 

Fair 

Good 

Good 

Fair 

Good 

Fair 

Good 

ChxKi 

Good 

Good 

Good 

Good 

Good 

Good 

Fair 

Good 

Good 

Good 

Good 

Good 

Fair 

Fair 

Good 
Good 

Good 



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B(zcteriological aixd Experimental In/vestigcUians, 1906. 107 

M. melUensis, was 1 in 10. The micrococcus could not, however, be 
detected in either blood, spleen, or inguinal or mesenteric glands. 
Three other horses (Nos. 11, 35, and 52), whose blood during life 
showed no signs of the presence of agglutinins, were examined post 
morteniy but with completely negative results so far as related to the 
presence of M. meliiemns. 

Details of the animals, relating to the length of service in Malta with 
the Mounted Infantry, their present condition, and previous medical 
history, were kindly supplied by tte oommanding officer, Captain 
Salmon, and such of those details as refer to hoTBes UMit gave a serum 
reaction are given in Table XXXIII. 

VI. — M. melUenm Infection by Means of Personal Contact. 

The incidence of Malta Fever upon cases admitted to naval and 
military hospitals for venereal disease, although probably due to 
infection by means of the goats' milk that forms the staple article of 
diet of the men during the first days of treatment, at once raises the 
suggestion that simultaneous infection might occur during sexual con- 
nection through minute lesions of the mucous membrane of the glands 
or prepuce, especially when considered in conjunction with the existence 
of M, mdUensis in the urine of so-called ambulatory cases of the 
disease. In these latter cases febrile disturbance is extremely slight 
or entirely absent, as indeed are clinical symptoms of any kind, 
although at the same time the patient, male or female, may be passing 
M, meUienm in thousands per cubic centimetre in the urine. 

Writing in the 'Journal of the Koyal Army Medical Corps,'* 
Kennedy stated that of the cases which developed Malta Fever after 
admission to the military hospital for some other disease, by far the 
larger proportion were venereal cases. The experience of the 
authorities at the Koyal Naval Hospital appears to be very similar. 

Following up this line of enquiry, the before-mentioned observer 
collected in 1905, and followed out, a series of 124 cases, 20 of which 
had been under treatment for venereal disease during some portion 
of the couple of months preceding the diagnosis of Mediterranean 
Fever. Again, of these 20 cases the probability of infection contracted 
within the hospital cotdd be excluded with tolerable accuracy in 12, 
viz., 6 cases of gonorrhoea, 1 of soft sore, and 5 of syphilis. 

Under these circumstances an enquiry was instituted into the medical 
history of the common prostitutes of Malta. The investigation was 
much facilitated owing to the fact that the bulk of these women are 
Italians or Sicilians and, therefore, coming under the law with regard to 
aliens, are registered by the police, their addresses are known, and a 

* Kennedy, J. C, ** Malta Fever in the Military Hospital, Yalletto, Malto, 
during the years 1897—1904," * Joum. BjLM.C./ vol. 4, 1906, pp. 684—646. 



Digitized by VjOOQ IC 



108 Dr. Eyre, Major McNaught, Capt. Kennedy, and Dr. Zamniit. 



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Bacteriologieod arid Es&perimewtal Investigations, 1906. 109 



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110 Dr. Eyre, Major McNaught, Capt. Kennedy, and Dr. Zammit. 

tri-monthly medical examination is carried out by certain district 
medical officers. 

Preliminary enquiries elicited a definite history of an attack of Malta 
Fever varying in duration from two to twdve weeks in 3, and a history 
of "rheumatism" suspiciously like the neuritis associated with the 
Fever in 1, out of a total of 147 registered women. Next, specimens of 
blood were collected from 134 of those previously interviewed — the 
remaining 13 refusing to allow either finger or ear to be pricked in 
order to obtain samples — for the purpose of carr3dng out the agglutina- 
tion test. Of these 134, 93 (or 69*4 per cent.) gave a completely 
negative reaction, 12 (or 8-96 per cent.) a slight reaction, indicating 
probably either a recent extremely mild or very remote attack of Malta 
Fever, and 29 (or 21*64 per cent.) pelding reactions that pointed to 
present or recent more severe infections. 

Combining these two latter classes, it will be seen that no less than 
41 out of a total of 134, or 30*59 per cent., exhibited evidence of 
M. melUensis infection. 

The next step was to obtain vaginal swabbings and specimens of 
urine from such of the prostitutes as yielded a positive serum reaction 
and, by means of plate preparations, endeavour to determine the presence 
or absence of 3/. melUensis from these situations. 

Of the 41 women yielding positive serum reactions, five, finding their 
occupation gone owing to the absence of the Fleet from Malta, returned 
to their homes in Sicily, and further specimens could not be obtained 
from them ; four more absolutely refused to permit swabbings or 
specimens of urine to be taken; the remainder, 32 in number, 
aiforded specimens for examination on one, two, or three several 
occasions. 

In the collection of these specimens the vaginal swabbings were taken 
on ordinary sterile swabs such as are employed for collecting diphthe- 
ritic material (a piece of absorbent wool twisted round the end of a 
16-cm. length of iron wire, enclosed in a test-tube, and the whole steril- 
ised by dry heat), from just within the vaginal orifice or f ron> some portion 
of the lower third of the vaginal wall. A Sims speculum was then passed 
into the vagina and the mouth of the os uteri exposed, and some of the 
cervical mucus collected on other sterile swabs. With regard to the 
urine samples, it was rarely possible to obtain catheter specimens, and, 
consequently, after the vaginal swabbing had been taken, a sterile, 
wide-mouthed bottle was handed to the woman and she was instructed 
to pass water directly into it. In this way, although asepsis was 
somewhat neglected, specimens of urine remarkably free from extraneous 
germs were usually obtained. 

On arrival at the Laboratory, plate cultivations were prepared from 
each of the specimens as follows : — 

Vaginal or Cervical Svxibbing. — With a pair of sterile forceps the end 



Digitized by VjOOQ IC 



Bacteriological and UxpcnnietUal Investigations, 1906. Ill 

of the swab wire was bent up at right angles so as to form an L-shaped 
rod, the infected cotton-wool occupying the short ann. Using the 
instrument now as a spreader, the swabbing was smeared over the 
surface of three nutrose agar plates in succession, and the plates 
numbered in the order of their inoculation. 

Urine, — (a) One-tenth of a cubic centimetre of the urine sample was 
evenly distributed over the surface of each of four nutrose agar plates 
by means of a sterile L-shaped glass rod. 

(6) Twenty cubic centimetres of the urine sample were transferred to 
a sterile centrifuge tube and thoroughly centrifugaUsed. Nearly all 
the supernatant fluid was pipetted off and the deposit shaken up with 
the remaining half cubic centimetre of urine, taken up in a sterile 
pipette and divided between two Petri dishes of nutrose agar. By 
means of a glass spreader, the urine deposit was distributed all over the 
surface of the first plate, and with the same instrument two further 
nutrose plates were inoculated in series. The remainder of the urine 
deposit, placed on the second plate, was distributed over it in like 
manner by the help of a second spreader, and two further plates 
inoculated in series with it. 

After inoculation and labelling with distinctive niunber, etc., all the 
plates were transferred to the incubator at 37° C, and kept under 
observation up to the end of seven days. All suspicious colonies were 
tested by means of a senmi of high titre, and those reacting were 
verified by tinctorial and cultural tests. 

The details of the examinations are given in tabular form (p. 112), 
but the results may be briefly summarised as follows : — 

(1) Urine, — M, melitenm recovered on five occasions from four 

patients. 

(2) Cei-vical Mucus, — M, melitensis never recovered frgm this situation. 

(3) Vaginal Stoabbings. — M, melitensis recovered on two occasions from 

one patient convalescent from an attack of Malta Fever, and 
on one occasion from a patient who had suffered from a severe 
attack 18 months previously. 

In connection with the isolation of M, melitensis from vaginal 
swabbings, it is interesting to note that the micrococcus was isolated 
from the the same situation, and also from the milk and the urine in 
the case of a married woman, Mrs. A., about a week after her 
discharge as convalescent from the Married Families (Military) 
Hospital at Valletta. 

In view of the foregoing results an attempt was made to determine 
experimentally the possibility of infection taking place through the 
genital mucous membrane — a possibility which was rendered the more 
probable by reason of Shaw's successful infections through the apparently 
intact conjunctival mucous membrane (see these Reports, V, p. 10). 



Digitized by VjOOQ IC 



112 Dr. Eyre, Major McNaught, Capt. Kennedy, and Dr. Zammit. 



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Bacteriological and Experimental Investigations, 1906. 113 

A prolonged search was first made for an infected milch goat which 
should combine the two factors — readiness for impregnation and the 
excretion of urine containing M. melitensis — ^but without success; 
consequently the demonstration of the infection of the healthy male 
goat as a sequent to covering the suitable infected female had perforce 
to be abandoned. Monkeys were available but proved refractory 
owing to the vicious nature of the females, and pairing was un- 
successful. Finally, two healthy male monkeys were selected; first 
one and then the other was securely held on the operating table, the 
glans penis exposed and carefully examined with a hand lens for 
scratches and abrasions. As the mucous membrane in each case 
appeared to be intact, the following experiments were made : — 

(1) A strip of cotton-wool was first dipped in a fresh specimen of 
urine from an ambulatory case of Malta Fever (under observation in 
H.M. Naval Dockyard), then wrapped around the glans penis of Monkey 
No. 203 and left in contact with the mucous membrane for a period of 
half a minute. The wool was then removed, the glans mopped dry 
with sterile cotton-wool and the monkey returned to his cubicle. 

The specimen of urine was then plated out and the subsequent 
growth showed the presence of 500 colonies of M, meHierisis per cubic 
centimetre. 

On the 17th day the blood serum of Monkey No. 203 in dilution of 
1 in 20 caused typical clumping of M. melitensis. The titre of the 
serum gradually rose until on the 28th day it had reached 1 in 150. 
The animal was then killed with chloroform vapour, and at the post- 
maiiem examination the micrococcus was recovered in large numbers 
from right and left inguinal glands, and in smaller numbers from the 
right axillary gland and the spleen, but was absent from the blood ; 
the post-mortem also revealed the fact that this monkey was the subject 
of miliary tuberculosis. 

(2) After exposing the glans of Monkey No. 200 it was first dried 
with sterile cotton-wool, and then a small area of the surface was 
rubbed with a dry, hard pad of sterile cotton-wool to produce a 
" friction " excoriation. A piece of wool soaked in the same specimen 
of urine that was used for the first experiment was wrapped around 
the glans and left in contact for 30 seconds. It was then removed, the 
glans dried and the monkey returned to his cage. 

On the 17 th day an agglutination reaction in dilution of 1 in 10 
was obtained and by the 28th day the serum value had risen to 
1 in 200. The animal was killed on this day and at the post-mortem 
the M. mditenms was recovered from the blood — to the number of 
aYK)Ut 10,000 per cubic centimetre — and in large numbers from the 
spleen, the axillary, inguinal, and mesenteric glands. 

Both these experiments, therefore, yielded positive results, infection 
taking place in the first -case by absorption of the coccus through an 
(13984) i 

Digitized by VjOOQ IC 



114 Dr. Eyre, Major McNaught, Capt. Kennedy, and Dr. Zaiiiniit. 



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Bacteriological cuid Experimental Investigations^ 1906. 115 

apparently uninjured and intact mucous membrane, and in the second 
case probably through the artificially produced lesion — in both the 
incubation period extended to 17 days, an interval between exposure 
to infection and the first appearance of symptoms which tallies very 
closely with those noted by Shaw in the experiments previously 
referred to. 



VII. Prophyiactic Inoculation with M. melitensis Vaccine. 

The results that had attended the use of Af, melitensis vaccine during 
the winter of 1905-6 by one of the members of the Working Party 
in the treatment of cases of Malta Fever after return to England, 
encouraged the hope that its emplojmient as a prophylactic vaccine 
might be a measure of practical utility, and arrangements were made 
to put it to the test. 

As the records of the Royal Naval Hospital at Bighi and of the 
B.A.M.C. Detachment in Malta showed an abnormally high case- 
incidence amongst those men whose duty it was to nurse Malta Fever 
patients, it was decided to limit the vaccination for the summer of 
1906 to this section of the community. The plan being explained to 
the men, a sufficient number of the Sick Bay Staff and Nursing 
orderlies expressed their desire to submit to the inoculations, to admit 
of the full strength being divided into two nearly equal batches both 
at the Military and the Naval Hospitals — one section at each 
institution being untouched or injected merely with sterile saline 
solution to serve as controls. 

The Subjects — XamL — Of the staff of the Naval Hospital at Bighi, 
43 men were available for observation in this connection, of whom 23 
were vaccinated (7 on one occasion only and 16 on two occasions) and 
20 were reserved as controls. From the 23 vaccinated men, however, 
two must be deducted, for the danger that must always exist in 
oanying out a series of vaccinations within the endemic area was here 

Table XXXVII.— Incidence of Malta Fever on the Bighi Hospital 

Staff. 





1901. 


1902. 


1908. 


1904. 




Members of Sick Berth Staff 
exposed to infection 

Number contracting Malta 
Ferer 


81 
5 


51 
19 


66 
12 


76 
16 


80 43 
12 18 





encountered and two of the men were vaccinated — each with a dose 
of 200 millions of cocci — during the incuhation petiod of the 
(13984) i 2 

Digitized by VjOOQ IC 



116 Dr. Eyre, Major McNaught, Capt. Kennedy, and Dr. ZammitL 

naturally acquired disease. This leaves 21 inoculated men and 
20 controls who were under observation from April 27th to- 
August 30th, 1906. During this period one of the controls contracted 
the disease, but no cases occurred amongst the vaccinated men. 

The incidence of Malta Fever on the Sick Berth Staff during 
previous years is shown in Table XXXVII. 

Military. — The strength of the Valletta detachment of the Boyal 
Army Medical Corps (RA.M.C.) at the commencement of the experi- 
ment comprised 84 men, of whom 12 had already suffered from an 
attack of Malta Fever, and four were then in hospital. This left 
a balance of 68 available for the purposes of observation. Of these 
30 volunteered for inoculation, the remaining 38 served as controls. 
The fallacies involved in such a division have already been threshed out 
in connection with prophylactic inoculations of typhoid vaccine, and need 
not be further enlarged upon here. Suffice to say, that of the inoculated 
men 15 received one injection only, and 15 received two injections ; and 
during the four months, from April 26 to August 30, 1906, that the 
men were under the observation of the operator, two cases occiured 
amongst the non-vaccinated controls, and none in the vaccinated men. 

At the beginning of September, however, two cases occurred in the 
vaccinated men. The first, Lance-Corporal Johnson, assistant in the 
Commission Laboratory at Valletta, who had been injected twice with 
a dose of 400 millions of cocci on each occasion, and whose serum value 
had reached 1 in 50, suffered a typical attack, and the second. Private 
Boyd, who had been inoculated once only with a similar dose, and whose 
serum had a value of 1 in 30. 

Owing to the distribution of the units of the detachment over the 
whole island for duty at the various military hospitals, and the 
frequent changes of station that take place, it is difficult to tabulate 
the incidence of Malta Fever in that portion of the detachment 
stationed at Valletta Hospital. Dealing, however, with the period 
January 1 to April 30, 1906, in an average strength of 81 (including 
12 who had already suffered from the disease), five cases of Malta 
Fever occurred, whilst during the period May 1 to August 21, 1906,^ 
with a strength similar in numbers and composition, only two cases, 
both in non-vaccinated controls, occurred. 

The Vaccine. — The vaccine employed was the remainder of a batch 
prepared and bulbed on March 16, 1906, in the Bacteriological 
Department of Guy's Hospital. The method of preparation varied in 
no respect from that usually adopted, and may be briefly described, 
first premising that all apparatus and solutions employed must be 
absolutely sterile, and every operation carried out imder strictly 
aseptic conditions and with every possible precaution to avoid the 
entrance of extraneous micro-organisms. 

A virulent culture of M, melitensis direct from the spleen of a 



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Bacteriological and Eocpcrinuntal Investigations, 1906. 117 

guinea-pig, dead from M, melitensis septicaemia within 24 hours 
of intracerebral inoculation, is carefully emulsified in about 5 c.c. of 
sterile saline solution and transferred to the glass reservoir of an 
aseptic " laryngeal spray." By means of this little spraying apparatus 
the emulsion is evenly distributed over the surface of the " optimum " 
reaction ( + 8) agar contained in each of several culture bottles of 
•either the Roux or the KoUe pattern. After insemination the culture 
bottles are incubated aerobically at 37° C. for from 24 to 36 hours. 
At the end of the incubation period the growth in the culture bottles 
is examined visually to determine its freedom from gross contamina- 
tion ; by means of stained preparations to determine its purity ; and 
by the agglutination test with serum of high titre to determine its 
identity. The culture proving satisfactory, 5 c.c. of a 0'1-per-cent. 
saline solution are pipetted into each bottle, and by means of gentle 
agitation caused to take into suspension the upper layers of micrococci 
in the growth. 

The tiurbid fluid is then pipetted off into a flask, which is labelled 
-'* A," and which receives in turn the surface washings from each of the 
•culture bottles. A further 5 c.c. saline solution is introduced into the 
eulture bottle, and the remainder of the growth is emulsified as evenly 
as possible with the help of a curved glass or platinum rod; this very 
turbid emulsion is transferred to a second flask labelled **B," con- 
taining a number of glass beads. When this process has been 
repeated with all the rest of the culture bottles and the emulsion added 
to that already in the flask with the beads, the flask with its contents 
is vigorously shaken at short intervals during the next half hour or so 
in order to disintegrate as far as possible any clumps of micrococci 
that may be present. The emulsion is then transferred to centrifugal 
tubes, placed in an electrical centrifuge, and run at a speed of some 
:2500 revolutions per minute for 30 minutes. At the end of this time 
a considerable deposit will have been thrown down, which is left 
behind in the tube, while the supernatant fluid is pipetted off and 
added to the surface washings from the culture bottles in the first 
flask. The centrifugal deposit is usually destroyed, but if a large 
quantity of vaccine is urgently required the deposit is returned to the 
flask '^ B," a few cubic centimetres of the saline solution added, and 
the shaking with the beads repeated. Further small quantities of 
saline solution are added from time to time during the process until 
an emulsion is formed which, to the naked eye, presents an opacity 
rather denser than that present in the emulsion in flask " A." This 
■emulsion is again centnfugalised, and the supernatant fluid may 
be pipetted off and added to the emulsion in flask '* A." 

The emulsion in flask " A " is now ready for the enumeration of its 
contained micrococci, which is done by Wright's method if time is of 
supreme importance. 



Digitized by VjOOQ IC 



118 Dr. Eyre, Major McNaught, Capt. Kennedy, and Dr. Zammit. 

Wright's method consists of taking into a capillary Pasteur pipette> 
furnished with a rubber teat, three equal volumes of a solution 
containing 0'75-per-cent. sodium chloride and 1-per-cent. sodium 
citrate, one volume of normal blood direct from a needle puncture 
of the finger or ear (and assumed to contain 500 millions of red cells 
per cubic centimetre), and one similar vohune of the emulsion of 
cocci. These various fluids are ejected from the pipette on to a slide 
and mixed thoroughly by repeatedly aspirating into and ejecting from 
the pipette ; finally, the mixture is transferred to a clean slide, and 
with the help of a second slide a blood film is prepared in the usual 
way. This is stained by Jenner's or by Leishman's stain, and 
examined microscopically with a 1/12-inch objective; then by the 
enumeration of the red cells and of the micrococci respectively in 
a number of " fields ** an average is struck for the ratio of the one 
to the other, and from this ratio is calculated the number of micrococci 
present per cubic centimetre of the emulsion. 

Whenever possible it is desirable to control this method by ordinary 
plating methods — after such dilution of the emulsion as may be 
deemed necessary — incubating for three days at 37° C, and enmnerat- 
ing the resulting colonies by the help of a counting disc. 

Whilst the enumeration is in progress the emulsion is distributed^ 
in quantities of 10 c.c, in as many sterile test-tubes plugged with 
cotton-wool as may be necessary ; the tubes are then suspended on a 
water bath running at 60*" C, and allowed to remain there for hall 
an hour from the time the water in the bath rose again to 60*" C. 
after its temporary fall consequent upon the introduction of the tubes. 
At the end of this time the tubes are removed from the water bath 
and suspended in a bath of running water to cool them down rapidly. 
Next 0*1 c.c. of emulsion is removed from each of several tubes, and 
surface plate cultivations established from each sample in order to 
demonstrate the absence of living cocci from the emulsion. The 
tubes of crude vaccine are then protected by indiarubber caps slipped 
over the cotton-wool plugs, and set aside in the ice chest until the 
result of the enumeration is known. 

Having measured the bulk of the crude vaccine and determined 
the number of cocci present per cubic centimetre, a very simple 
calculation decides the amount of diluent to be added to the emulsion 
to reduce the number of cocci present per cubic centimetre to, say, 1000 
millions, which is, perhaps, the most useful standard. The diluent 
employed is a 0'1-per-cent. saline solution, the necessary quantity of 
which is measured out into a large flask, and to it is added tricresol 
in such amount that the finished vaccine shall contain 0*25 per cent, 
of the disinfectant, tricresol being employed in preference to phenol 
or lysol on account of its lack of irritating properties. 

The crude vaccine is now transferred by means of sterile pipettes 



Digitized by VjOOQ IC 



Bacteriological and EocperiTneivtal Investigations, 1906. 119 

from the tubes in wbich the emulsion was sterilised to the flask 
containing the diluent and antiseptic, in which thorough mixture is 
effected. This flask is next connected up to the side feed of a 
graduated burette, and the vaccine filled into glass bulbs in quantities 
of 0*5 and 1 c.c. as required, the bulbs sealed off, in the blow-pipe 
flame, and labelled, with a writing diamond, with some distinguishing 
character or number, which indicates the character and number of 
cocci in suspension inside the bulb. 

The Inoculations : Time, — The inoculation was usually performed the 
last thing at night (10 P.M.), so that several hours' rest in bed 
inten'cned before the heavy work of the following day commenced. 
In many instances, however, 11 A.M. or noon was the hour at which 
the injection was made, but so far as could be ascertained, the time 
at which the inoculations were carried out exercised no influence 
upon the immediate clinical results. 

Site. — The site of inoculation was the subcutaneous tissue of the 
abdominal wall just below the costal margin. The skin in this 
situation was prepared by thoroughly cleansing a small area with a 
2-per-cent. solution of lysol applied with cotton-wool, then removing 
all trace of the antiseptic by directing a stream of ether from a drop 
bottle on to the spot, or swabbing it well with a pad of wool 
saturated with ether. The ether served a subsidiary purpose, in that 
by its rapid evaporation it cooled the prepared area of skin and 
reduced its sensibility. 

Dose. — The inoculations were made with the help of a hjrpodermic 
needle attached to a 10 or 20 c.c. syringe, holding 20 or 40 doses 
respectively, as the bulk of inoculum was invariably 0*5 c.c. By 
using a large syringe supplied with a number of spare hjrpodermic 
needles, it was only necessary to replace the soiled needle by a fresh 
sterile one, after each inoculation, and proceed to the next individual, 
thus saving much valuable time when many men had to be inoculated. 

The vaccine brought from England for the purpose of these 
inoculations was numerically stronger than usual, and contained 
2500 million cocci per cubic centimetre, so that the number of 
organisms per dose could readily be varied by suitable dilution of the 
emulsion. 

The initial dose varied slightly in individual cases, but was either 
two, three, or four hundred millions of cocci. Subsequent doses were 
regulated by the response of the individual to inoculation, as judged by 
the movements of the curve representing the agglutinin-titre of the 
serum, but were usually 400 millions of cocci. 

After the hypodermic injection of the vaccine, a wisp of cotton-wool 
and a drop of flexile collodion sealed the needle puncture and supplied 
all the dressing necessary. 

In many of the cases two inoculations were given at suitable intervals. 



Digitized by VjOOQ IC 



120 Dr. "Eyre, Major McNaught, Capt*. Kennedy, and Dr. Zammit. 

Sequeke of Inoculatums. — Before giving the details of the inoculations 
carried out, and their results, a few words are necessary as to the local 
and constitutional effects following the introduction of the dead bodies 
of M. melUensis into the subcutaneous tissue of the normal human 
subject, as observed in these 51 men. 

Local Appearances. — The introduction of such a small quantity of 
fluid into the subcutaneous tissue produced no immediate effect other 
than a slightly marked prominence of the skin at the seat of inocula- 
tion. Usually the emulsion was completely absorbed within a few 
hours, and on the morning following the inoculation no local alteration 
was discernable. In three of the orderlies of the R.A.M.C., the first 
inoculation was followed by a very distinct, hard, tender lump at the 
seat of inoculation, the skin over the swelling being red and slightly 
(edematous. Some tenderness of the inguinal and axillary glands was 
present so long as the lumps remained tender, but this passed off 
rapidly when the swelling had disappeared. In all three cases the 
swelling subsided without interference, the duration of a visible tumour 
being limited to two or three days respectively in the first two cases. 
In the third, the lump, which was on the right side, remained visible and 
tender for seven days, and was probably due to the fact that the subject 
— an ardent cricketer — was on bowling for practically the whole of the 
afternoon following inoculation. Several of the Sick Berth Staff of the 
Bighi Hospital complained of pain at the site of the needle puncture 
after the first injection, but in each case this was found to be due to 
the pull of the shrinking collodion on the surrounding fine hairs and 
not to any alteration in the tissues at the point where the emulsion of 
cocci was deposited. Inoculations subsequent to the first failed to cause 
any discomfort. The inguinal glands in many were slightly tender for 
the 24 hours following an injection, but not longer. 

ConstUutional Symptoms, — Beyond slight headache and feeling of 
malaise, associated with a rise of temperature to 98*' '6 F. or 99' F., 
complained of by a few on the day following inoculation, no consti- 
tutional symptoms were observed. Two of the controls, however, who 
had been injected with normal saline solution complained of severe 
headache and showed temperatures of 99''*6 F. and 99° 8 F. respec- 
tively on the day following the injection. It will thus be seen that 
none of the disquieting results recorded by Lieut. Bousfield, R.A.M.C.,* 
were noted in this series of inoculations. That they do occur, however, 
was well shown in the case of one of the members of the Working Party 
who was inoculated by Lieut-Colonel Leishman immediately prior to 
leaving England. Marked enlargement, accompanied by tenderness 
on pressure of the superficial lymphatic glands was observed within 
24 hours of inoculation, together with some headache and malaise. 

* Bousfield, L, " Some Bemarks on Protectire Inoculation against Malta Ferer,*' 
* Journ. R.A.M.C.,' toL 7. 1906, pp. 179—182. 



Digitized by VjOOQ IC 



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Bacteriological aiid Experimental Investigations, 1906. 123 

The seat of inoculation was occupied by a raised, hard, and tender 
lump, which gradually became soft and boggy to the touch, and the 
skin over it acquired a dusky-red colour. As there was every evidence 
of pointing, the tumour was incised on the 11th day and some thin 
serous pus, which proved sterile, was evacuated; and no higher 
dilution of the blood serum than 1 in 10 would give a positive 
agglutination reaction. 

Later on an injection of the same brew of vaccine that was used in 
the series of prophylactic vaccinations now under consideration was 
introduced into the opposite flank. This was followed by a precisely 
similar train of events, although on this occasion the symptoms were 
distinctly less severe : the agglutination response on this occasion rose 
to 1 in 40. 

Ketuming once more to the series of inoculations carried out upon 
men of the Naval Hospital and of the R.A.M.C. it must be noted that 
the response of the individual as judged by the movements of the 
agglutination value of the serum varied within wide limits from 
a positive reaction in a dilution of 1 in 200 to a negative reaction in 
a dilution of I in 5 as a residt of the first injection. 

A further point to be noted in the tabulated details is the very 
distinct fall in the titre of the serum that has taken place by the end 
of the four months, in one case from 1 in 200 to 1 in 10, showing that 
the individual response to vaccination, so far as relates to the produc- 
tion of antibodies of the agglutinin group at any rate, is limited to a 
comparatively short period, and apparently indicates that a further 
inoculation is necessary at the end of about three months after the first 
or second. 

The immmiity of the inoculated men during a period of four 
months from any attack of Malta Fever, though possibly due in 
part to the elimination of the " goat's-milk " factor, points to the 
necessity of a further trial of the if. meUtensis vaccine — on a large 
scale ; and in this case it would be of advantage to inoculate a large 
l>ody of men, say half a regiment, before they enter the endemic area 
and then again after some three months' service in Malta. 

VIII. CuNiCAL Observations. 

The limited time at the disposal of those members of the Working 
Party who were engaged in the Bacteriological and Experimental 
Investigation, no less than the paucity of cases occurring during the 
summer of 1906, precluded any extensive observations being carried 
out in connection with the clinical side of Malta Fever as it occurs in 
man. Certain points were, however, enquired into, and the results 
obtained are inserted here rather as indications of lines of research 
requiring further elucidation, than as dogmatic statements from which 
definite conclusions can be drawn. 



Digitized by VjOOQ IC 



124 Dr. Eyre, Major McNaught, Capt. Kennedy, and Dr. Zammit. 

Under these circumstances a bald outline of the observations made 
.and the results obtained are all that are necessary, and these may be 
arranged under separate headings for convenience of reference. 

(a) Bhod. — Presence of Micrococci therein. — The presence and 
multiplication of M. melUensU in the blood of Malta Fever patients at 
various stages of the disease is now an established fact and fixes the 
position of the infection as a definite and specific septicaemia, though 
the researches of Gilmour and Shaw appear to indicate that the 
number of cocci present per cubic centimetre in the peripheral blood 
is usually small. A consideration of the work of these observers, 
however, led to the conclusion that if cases in the very early stages of 
the disease, at or near the summit of a period of pyrexia, were selected 
for observation and blood collected late in the day, relatively more 
•organisms would be found than had hitherto been noted. A careful 
scrutiny of the case notifications enabled three cases to be eventually 
■selected as especially suitable, and one obsenration was made on each 
patient. 

The technique of the blood collection was that usually employed 
in hospital work in England ; that is to say, the forearm was 
carefully washed, lathered with soft soap and shaved, then washed with 
lysol (2-per-cent. solution) and finally cleansed with ether, and 
a bandage was bound tightly about the arm above the bend of the 
•elbow. The interior of a 5-c.c. all-glass syringe was next moistened 
with 10-per-cent. solution of sodium citrate in normal saline by first 
filling and then emptying the barrel ; the object, of course, being to 
prevent any alteration in the physical condition of the collected blood, 
such as general or local clotting, between the moment of filling the 
syringe and of transferring the blood to the nutrient medium. The 
needle was then thrust into the lumen of either the median basilic or 
median cephalic vein and the syringe itself depressed and allowed to 
fill with blood as the piston was gradually withdrawn by gravity. . 

A series of test-tubes filled with accurately measured quantities 
of nutrient broth bad previously been arranged in a test-tube rack. 
One cubic centimetre of the blood was then added to 9 c.c. of 
nutrient broth in the first test-tube and thoroughly mixed — this tube 
was labelled No. I. From Tube No. I, O'l c.c. of the mixed blood 
and broth was removed by a sterile graduated pipette and added 
to 9-9 c.c. broth in Tube No. II; 0*1 c.c. of the contents of 
Tube No. II were then added to 9*9 c.c. broth in Tube No. IIL Next 
1 c.c. of the contents of Tube No. I was added to a fresh tube of 
broth labelled Tube 1 : then 0*1 c.c. from Tube No. I was added 
to another tube of broth numbered Tube 2, This process was then 
repeated with the two other tubes marked with Eoman numerals, 
the Arabic figures S, ^, J, and 6 being employed to distinguish the 
.secondary tubes inoculated therefrom. 

Thus a series of dilutions was obtained as under : — 



Digitized by VjOOQ IC 



Bacteriological and Experimental Investigations, 1906. 125- 













of blood. 


Tube I contained 1 (approximately) 


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respectively. 

Finally the 4 c.c. of blood remaining in the syringe were distributed 
amongst several tubes of broth to guard against the possibility of total 
failure to obtain a growth, which might otherwise happen if only a few 
cocci were present in the blood collected. 

All the tubes were then incubated at 37"* C. for preliminary enrich- 
ment, and on and after the third day plates were inseminated with 
broth from such of the tubes as showed naked eye growth. 

Then by noting the tube containing the smallest quantity of blood 
from which the micro-organism was recovered it became an easy matter 
to calculate the number of cocci present per cubic centimetre in the 
peripheral blood of the patient. 

By following this procedure the coccus was found to be present in 
all three cases in fairly large numbers. The following are the details 
of these cases : — 

1. Private Kirton — onset of disease, 18.6.06 : admitted to hospital, 

21.6.06. Blood collected, 25.6.06 at 7 p.m. Serum agglutina- 
tion value — 1 in 2000. M, nielitensis present to the number of at 
least 1900 per cubic centimetre. 

2. Private Fitzgibbon — onset of disease, 28.5.06 : admitted, 31.5.06. 

Blood collected, 5.7.06 at 7 p.m. Serum value — 1 in 200. 
M. msUtensis present to the number of 10,000 (but not 100,000) 
per cubic centimetre. 

3. Private Kearney — onset of disease, 20.5.06: admitted, 23.5.06.- 

Blood collected, 5.7.06, at 7.30 p.m. Serum value— 1 in 200. 
M. melitensis present to the number of 1000 (but not 10,000) 
per cubic centimetre. 

2. Leucocyte Formula. — ^The work of the French observers in Tunis — 
Hayat, Cathoire, Cardaliguet, SchouU, etc. — tends to show that th& 
leucocyte formula of the blood in Malta Fever cases presents a consistent 
variation from the normal, and to this variation is attached diagnostic 
importance. The variation is stated to be in the direction of a relative- 
and often an absolute increase in non-granular cells; and the few 



Digitized by VjOOQ IC 



126 Dr. Eyre, Major McXaiight, Capt. Kennedy, and Dr. Zaminit. 






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Bacteriological and Mcperimoital Investigatiom, 1906. 127 

observations made during the summer on this point afford some 
confirmation of these statements. 

In four cases a complete blood examination was carried out, the red 
and white cells being enumerated by the aid of the Thoma Zeiss 
hiematocytometer, the haemoglobin estimated in a Gower's hsemoglo- 
binometer, and a differential leucoc3rte count, made on films, stained by 
Jenner's method — the classification adopted under the last heading being 
that advocated by PriceJones,* to whom we are greatly indebted for 
confirming the accuracy of the counts. The results obtained are 
tabulated in Table XL, from which it will be seen that in three there 
was a very marked rise in the non-granular cell-content of the blood. 
In the fourth the deviation from normal was only noticeable in the 
deficiency of hsemoglobin. 

(b) MiUc. — ^Although, arguing from analogy, it was a foregone con- 
clusion that M. imlUensis would be found in human milk, actual 
demonstration had hitherto been wanting on account of the inf requency 
of lactation being associated with Malta Fever. During the summer of 
1906 opportunity was afforded of investigating three cases only, but 
from two of these the micrococcus was recovered. 

In collecting specimens of the milk, the breast was first washed up 
with soap and water, then with ether, then the bell opening of a sterile 
glass breast pump was applied and the milk received in the side bulb. 
Details of the successful recoveries are as follows : — 

Mrs. A., Military Family Hospital, Valletta. Onset of disease, 7.5.06. 
Date of delivery, 24.6.06. The flow of milk was scanty from 
the first and the mother was unable to suckle her infant, 
which was consequently hand-fed on condensed milk. A sample 
of milk was collected from the right breast 26.6.06. The 
milk, which was yellowish in colour and distinctly oily, gave 
a complete agglutination reaction in dilution of 1 in 100. 
Single drops (about 0*03 c.c.) were used to inseminate each of 
about a dozen plates, which after incubation yielded about half- 
a-dozen colonies of M, ineliiensis per plate, so that each cubic 
centimetre of milk contained about a couple of hundred 
micrococci A second sample of milk collected 5.7.06, required 
the exercise of powerful suction before even a couple of cubic 
centimetres could be obtained. The agglutination reaction was 
now obtainable in dilution of 1 in 2000, and M. melitensis was 
present to the number of some 300 per cubic centimetre. 

C. G., Misida. Attack of Malta Fever, September — December, 1904, 
during the puerperium. The milk practically dried up and the 
child was hand-fed. Eighteen months later (June, 1906) patient 

• Jones. C. Price, 'Brit Med. Journ.,' 1906, toI. 1, pp. 409, 410; 1906, rol. 2, 
pp. 1112, 1118. 



Digitized by VjOOQ IC 



128 Dr. Eyre, Major McNaught, Capt. Kennedy, and Dr. Zammit. 



Table XLI. — M, meliiensis in Urine of Ambulatory Cases. 



Date of 

plating. 



1867. B.Woriey. 



Troatmont. 



Nnniber of 

oolonies of 

M, melitensi* 

per CO. 



3414. F.Mallia. 



Treatment. 



If mnber of 

oolonies of 

M, melitensU 

per C.C. 



April 20 



nil 



Kaj 



Jnne 



27 

1 

4 

8 

11 

15 

18 

82 

25 

29 

1 



July 



12 ... 
15 ... 
19 ... 
22 ... 
26 ... 
29 ... 
8 ... 
6 ... 
„ 20 .... 
„ 24 ... 
„ 27 .... 
„ 81 .... 
Aug. 1—14' 



„ 21 ... 

„ 24 ... 

„ 28 ... 

» 81 .,.j 

Sept. 4 

7 

„ 11 

» 14 

„ 18 

„ 21 

„ 26 



" 



Daily from 
18/8/06 

to 

81/8/06 

peroxide of 

succinic acid, 

as Mallia 

nU 



440 
1,800 

720 
8.000 

186 
2,850 
1,800 
1,000 
1,060 

860 
1,900 

00 

0. J 

on leave 

40 

2,140 

180 

10 

160 

240 

1,068 

8,890 

110 

2,565 

1,020 

2,210 

not enumerated. 

but 

Jf. melitenM 

constantly 

present 

600 

1,242 

28 

801 

705 

6,800 

24,140 

14,000 

8,600 

2,660 

6,716 

7,600 



Daily from 
27/4/06 

to 
1/6/06 
peroxide of 
suooinioaoid 
2 grs. p. aq. 
dist. ad. 8 X. 



nil 



i-^ 



9,000 
2,000 
12,000 
21,000 
800 
10,600 
12,000 

00 

600 

600 

950 

1,600 

00 

nil 



nU 



nil 



no sample 
nil 



X — innumerable. 



Digitized by VjOOQ IC 



Baetmolofiical mid E:qwnmental rnvestif/ations, 1906. 129 

states that flow of milk has never entirely ceased — small 
quantities can still be squeezed from the gland. A sample of a 
couple of cubic centimetres collected in the sterile breast pump 
by the aid of a combination of suction and expression on three 
several occasions. The milk, which appeared normal in colour 
and consistence, gave a positive reaction in dilution of 1 in 200. 
Plate cultivations to the number of three were prepared, each 
with 0*5 c.c. of the milk at each examination. At the first and 
third 3f. melitenm could not be detected in the resulting growth, 
but at the second examination saprophytes were practically 
absent, and colonies of M. Tnelitensis to the average number of 25 
were present in each of the three plates, i.e., average 50 per 
cubic centimetre. 

(c) Urine. — The two cases of Ambulatory Malta Fever in workmen 
in E.N. Dockyard handed over by Staff-Surgeon Shaw, RN., when he 
left Malta,* were kept under observation during the summer. 

No. 3414, F. Mallia, was treated from 24.4.06 to 1.6.06 with peroxide 
of succinic acid in the form of a 1 iu 10,000 solution, 5 ounces of the 
solution being administered morning and evening, and by June 15 the 
31. melUensis had disappeared from the urine. 

No. 1857, B. Worley, who served as a control to the previous case 
whilst peroxide was being administered, continued to pass urine con- 
taining large numbers of M, mditensis until October, when the 
examination of his urine was discontinued, although he, too, had been 
put on the peroxide in similar doses for a fortnight from 18.8.06 
to 31.8.06. 

(d) Fceces, — Only one or two observations were made with a view to 
the detection of M, melitenm in the faeces. The results so far as 
concerned firm, formed motions, were negative, but in one fatal case 
(Private R.) of one and a-half months' duration, where the intestines 
were filled with light semi-fluid faeces, the presence of M, melitenm in 
considerable numbers was demonstrated after plating on ox serum 
nutrose agar.t 

(e) Posi^noriem Examinations. — But two fatal cases of Malta Fever 
occurred during the first eight months of 1906 in the K.M. 
Hospital, Valletta, upon which post^iortem examinations were held. 
The details of these are here tabulated. 

Several post mortems (which were witnessed by the courtesy of the 
staff of the Civil Hospital) were conducted on fatal cases of Malta 
Fever, but in these systematic bacteriological investigations were not 
carried out. 

• See these Bepoits, IV, p. 12 and V, p. 40. 

t Eyre, J. W. H., "The Preparation of Nutrose Agar," * Trans. Path. See.,* 
Tol. 55, 1904, pp. 91-106. 

(13984) k 



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130 Dr. Eyre, Major McNaught, Capt. Kennedy, and Dr. Zammit, 
Table XLII. — Post-mortem Details. 



Organ or fcistue examined. 


Pte.D. 27/1/06. 


Pte. E. 81/5/06. 


Heart blood 


Af, melitetuis present 

not examined 

M, melUensit present 

not examined 

II 

»» 

M. melitenna present 

1) 
i» 
»» 
if 
not examined 


3£. melitensU present 
?» 
II 
II 

absent 

Jf. melUmm* present 

not examined 

i» 

II 

II 

M, meliUmU present 


Pericardial fluid 


Spleen 


Bile 


Inguinal glands 


M^liaetiiuil glands 


Mesenteric glands 


Salivarj glands 


Thyroid crlands 


Bppnmnal glands 


Pancreas 


Fesces 





IX. Comlusions, 

It must be noted that, in addition to breaking new ground, much of 
the experimental work of the Mediterranean Fever Commission during 
the summer of 1906 has necessarily been arranged in order to elucidate 
the previous work of individual members and to collate the recorded 
facts ; and from a general review of the whole question of M, melitenm 
infection in man, and in the light of our present knowledge, it may be 
fairly stated that — 

(a) The most common method of infection is by the ingestion of 

infective articles of food — mainly milk. 

(b) The next common path of infection is by subcutaneous inocula- 

tion during the handling of infective material — usually milk, 
(r) More rarely infection may occur as the result of contagion, or, 
possibly, through convection by means of blood-sucking insects. 

The results obtained by the Working Party during the summer of 
1906 have been summarised in the foregoing pages in connection with 
the headings to which they relate ; the more obvious and the more 
important of the conclusions arrived at are here recapitulated : — 

1. The goat is highly susceptible to infection by M, melilensis as the 
result of cutaneous, subcutaneous, intravenous, and intraperitoneal 
inoculation, and as the result of feeding with infective material. 

2. The course of the resulting septicaemia is extremely mild, and 
usually after the first few days cannot be demonstrated by clinical 
observation. 

3. In order to detect all the infected milch goats in any given herd 
it is necessary to repeatedly examine the milk at short intervals. 
In selecting milks for bacteriological examination a positive milk 
agglutination reaction (Zammit's test) is a much more reliable indication 



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Baderiological and U^^ertmerUat Investigations, 1906. 131 

of the presence of M. melitensis than is a positive serum agglutination 
test. 

4. During the course of the infection the M, Jtielitensis first disappears 
from the peripheral blood and from most of the viscera, next from the 
spleen and kidneys, next from the superficial lymphatic glands, and last 
of all from the mammary gland. 

5. The appearance of M, melitensis in the milk of the goat is a 
comparatively late phenomenon; the coccus present in this fluid is 
fully virulent, and the milk itself highly infective. The number of 
M. melitensis in the milk varies within wide limits from day to day, 
and bears no relationship to the severity of the infection, air 
temperature, etc. ; the presence of M, melitensis in the milk appears to 
be merely the residt of a mechanical flushing of the mammary gland 
by means of which the cocci multiplying therein are removed. 

6. M, melitensis is not destroyed during the processes incident upon 
the manufacture of the ordinary ice-creams, or of the native cheeses, 
and may be present in the retail articles living and unaltered in 
virulence. 

7. The association of infected milch goats in a herd Mrith cases of 
Malta Fever in the owner's family (the members of which do not as a 
rule partake of the milk) suggests the frequency of cutaneous inoculation 
through scratches and abrasions of the human skin. 

8. The administration by the mouth of infective goats' milk is 
usually followed in the monkey by an attack of M. melitensis 
septicaemia, 83 per cent, of the experimental animals yielding absolute 
and conclusive evidence post mortem of the existence of M. melitensis 
septicsemia, irrespective of the dose of infective bacteria. 

9. The eight members of the crew of the ** Joshua Nicholson," and 
one woman in the United States developed Malta Fever after the 
ingestion of infected milk under conditions which point to the absence 
of other sources of infection. 

10. Weak solutions of hydrochloric acid exert some slight bactericidal 
power on M. melitensis in vitro, which becomes more marked when 
pepsin is also present in the solution. The introduction of infective 
milk directly into the stomach was not, in the two experiments made, 
followed by M, melitensis infection. 

11. The mosquito (Acartomyia and Stegomyia) and the common 
blood-sucking fly (Stomoxys) can act as the host of M, melitensis for a 
short period, generally limited to four or five days, and during that 
time the bacteriimi retains its virulence unimpaired. 

12. M, melitensis can exist for many days in, and be recovered 
in a virulent condition from, the " droppings " of these insects. 

13. One only out of a number of experimental animals (in H of 
which exact data are available) showed signs post mortem of a mild 



Digitized by VjOOQ IC 



132 Dr. Eyre, Major McNaiight, Capt. Kennedy, and Dr. Zammit. 

infection by M, melUensis, subsequently to being bitten by highly 
infective mosquitoes. 

14. The existence of M, DielUensis in urine and vaginal swabbings of 
infected females, together with the successful inoculation of experi- 
mental monkeys through the mucous membrane of the glans penis, 
points to the possibility of infection in man during sexual congress. 

15. The inoculation of M, melUensis vaccine in the normal man 
is but rarely followed by any marked local or constitutional dis- 
turbance. 

16. The prophylactic use of one or two doses of such vaccine in 
some 60 cases appears to have afforded protection for a period of about 
four months, and suggests the necessity of repeating this observation 
on a large scale — the first treatment to be carried out prior to the 
entrance of the men into the endemic area. 

17. The therapeutic use of M. imlitensis vaccine appears likely to 
become a valuable method in the treatment of the infected milch 



18. Th^ few clinical observations that were made by the Bacterio- 
logical Section of the Working Party : — 

(1) Demonstrated the presence of M, melUensis in human milk and 

faeces. 

(2) Indicated the necessity for further investigation into the 

" leucocyte formula " in blood of Malta Fever cases in vievr 
of possible variations therein affording useful aid in diagnosis ; 
and also for further investigation into the phenomenon of 
the passage of M, mditensis in the urine with a view to the 
selection of one or more urinary germicides capable of 
destroying the cocci in the genito-urinary tract. 



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BacteriologiccU and UicperimerUal In/vestigaii&na, 1006. 133 



Eboommendations as to Preventive Measures in Conneotion 
WITH Mediterranean Fever in Malta. 

Various suggestions for the prosecution of a campaign against 
Mediterranean Fever arise from a consideration of the bacteriological 
and experimental data detailed in the Eeport of the work of the 
Mediterranean Fever Commission during 1906. 

These fall naturally into one of two broad groups which, for our 
present convenience, may be designated by the titles of " palliation " 
and *' eradication " respectively, and deal with the measures which must 
necessarily be adopted according to whether we merely wish to relieve 
our Navy and Army of the disastrous effects inseparable from the 
incidence of the disease, or to attempt the stamping out of Malta 
Fever from a dependency of the Crown which has, in the past, been 
considered of some strategic importance. 

The first point to which attention should be directed, no matter 
what preventive measures are ultimately instituted, is the provision 
of an efficient and thorough system of compulsory notification of 
Mediterranean Fever. The system should probably be introduced 
in the form of an " Ordinance," and modelled on the lines of that at 
present in force in the British Isles imder the Infectious Diseases 
(Notification) Act, 1889, and should be organised from a Central 
Office to which all notifications — naval and military as well as civil — 
should be sent. Provision should be made for the payment through 
the Public Health Department of fees (which in this instance need 
not exceed 6d. per notification) to civil practitioners in attendance on 
cases of Mediterranean Fever, and, on the other hand, for penalties for 
such as wilfully disregard the enactments of the Ordinance. 

FaUiaium, — Reviewing the evidence already collected by the 
Mediterranean Fever Commission in its entirety, it is fairly obvious 
that the infective character of the milk of many of the goats upon the 
island of Malta affords a ready and reasonable explanation of the 
means by which the disease is transmitted. Then, too, the evidence 
yielded by experiments upon monkeys, supported by the facts of 
tine 8.8. "Joshua Nicholson" epidemic, justifies the assumption that 
in the ingestion of infected milk we have the veritable infective 
agency in the vast majority of cases. Additional weight attaches to 
this view by reason of the declining case incidence that was associated 
with the compulsory substitution (owing to the goatherds' strike) 
of imported preserved milks for the fresh goats' milk by the local 
naval and military authorities. Consequently, the strict prohibition 
of the use of the local supplies of fresh milk by the garrison and 
fleet should result in a very large diminution of the wastage from 
Malta Fever» and is a preliminary measure which must be enforced 
(13984) k 2 



Digitized by VjOOQ IC 



134 Dr. Eyre, Major McNaugbt, Capt. Kennedy, and Dr. Zammit. 

during the period that will necessarily elapse before the existing 
supply of virus is appreciably influenced by the measures to be 
suggested with a view to the eradication ot the disease. Whether 
or no the time is yet ripe for the State supervision of the milk 
supplies, the erection of depdts, constructed upon sanitary principles, 
for the milking of goats and other animals, and the subsequent 
distribution of the milk, is an open question; but in any case the 
liberty of the goat to perambulate the streets of Valletta and other 
large towns, to feed from the garbage of the gutter, and to pollute 
the atmosphere, must be curtailed to the extent of prohibiting the 
entry of the animals into the fortified cities and barrack squares, if 
only to increase the efifectiveness of regulations based upon the above 
recommendations. 

Eradication, — The measures to be adopted under the preceding 
heading are comparatively simple, and when dealing with a disciplined 
body of men, such as compose our Navy and Army, fairly easily 
enforced. Measures for the stamping out of the disease, on the other 
hand, which have to be applied to the goat and other milk-yielding 
animals through the intermediary of the owner, must< needs bring 
the sanitary authorities into conflict with the usually uneducated and 
often violently prejudiced native of the agricultural class, and it is 
uncertain how far recommendations imder this head will, from the 
diplomatic point of view, commend themselves to the civil authorities. 
In the event of any or all such recommendations being adopted, the 
Ordinance upon which they are based will need to be administered 
with great firmness and tact. 

In the first place, it is essential that all the goats in the island 
should be registered, and some method should be employed of 
numbering by means of stamped metal discs (such as is already 
carried out in the case of dogs), which will aflbrd a ready means of 
identification of individual animals. Next, repeated analyses of 
samples of milk, taken at regular intervals, must be made in respect 
to every milch goat by medical oflScers of health (who need not be 
bacteriological experts) specially detailed for this purpose, at three, 
four, or more district "centres," where laboratories for the applica- 
tion of the Zammit milk test must be provided. Further, samples 
of the milk from each animal, giving a positive reaction with this 
test, must then be sent to the Central Laboratory in the Public 
Health Department at Valletta for bacteriological examination for 
the demonstration of the presence of M, imlitensis. iSo far the 
suggested measures are simple in theory, and by no means costly in 
practice ; nevertheless, unless carefully handled, the Maltese goatherd 
will offer considerable opposition to their execution. 

The remaining measures deal with the segregation of such infected 
anim ft^ as are found from time to time to be yielding milk containing 



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Bacteriological and Sxperimental Investigations^ 1906. 135 

the specific micro-organism of Mediterranean Fever, and will necessarily 
be more expensive in operation, though, considering the importance of 
the issue at stake, not unduly so. 

The total number of goats to be dealt with amounts approximately 
to 20,000, of which probably at least 2000 are infective, so that 
provision should be made on a liberal basis for dealing with possibly 
5000 animals during the first year's work. Wben an animal is 
definitely shown to be yielding infective milk, it should be at once 
seized by the sanitary authorities and transferred to the Lazzaretto, 
or some other "pound" to be subsequently established, the owner 
being compensated on a scale comparable to that employed in Great 
Britain when infective animals (e.g., in pleiu-o-pneumonia, tubercu- 
losis, etc.) are seized by the public health authorities, and the milk 
stall should be disinfected and lime-washed. As, however, the flesh of 
infected goats, etc., is harmless when cooked, considerably more than 
half of the animals thus seized could be slaughtered, the viscera 
destroyed, and the flesh sold for consumption — a proceeding which 
would materially lighten the cost of these preventive measures. More- 
over, as the progeny of infected milch goats is itself uninfected at birth, 
the seizure and destruction of infected animals should be combined 
in the case of the more valuable animals — the specially good milkers, 
etc. — with a modification of the " Bang process " for the reproduction 
of tuberculous herds, under the direct control of the Public Health 
Department, at special breeding faims where the selective in-breeding, 
which has rendered the Maltese milch goat such a valuable animal, 
could be continued under skilled supervision. This process, devised 
by Professor Bang, of the Copenhagen Veterinary College, as applied to 
tuberculous herds, has already been carried out with marked success 
in Denmark, Hungary, and the United States of America, and it 
appears probable that in dealing with the M. melitensis infection in 
goat the whole of the infective animals thus seized would be the 
replaced by healthy animals in the course of three or four years. 
Here, again, by the sale of yearlings a considerable return might be 
effected. While the capital sum required to organise and carry out 
all these measures in an efficient manner is greater than the civil 
authorities in Malta could readily devote to the purpose, the enormous 
saving in fighting material that would accrue to the Navy, and 
particularly to the Army, by the disappearance of Mediterranean 
Fever from the Maltese Islands, would amply justify an appeal to the 
Imperial Exchequer — assuming, of coiirse, that Malta retains its 
present importance as a base for our sea and land forces. 

Although, as is indicated later, certain powers are available already 
under Ordinance III of 1904, it would probably be preferable to 
introduce a new Ordinance for the purpose of stamping out Mediter- 
ranean Fever from the goats of the Maltese Islands, under the title 
of Infectious Diseases (Mediterranean Fever) Ordinance of 1907. 

Digitized by VjOOQ IC 



136 Dr. Eyre, Major McNaught, Capt. Kennedy, and Dr. Zammit. 

The various suggestions embodied in the foregoing paragraphs are 
here summarised. 

Regulations for the Prevention of Mediterranean Fever. 

I. General, 

1. Compulsory notification enforced under an Ordinance which 
provides fees for compliance with, and penalties for disregard of, its 
provisions. 

2. Popular education with regard to disinfection of excreta of 
patients suflfering from Mediterranean Fever. 

3. Prohibition, by Ordinance, of exportation (or importation) of 
goats, cows, ewes, asses, or other animals yielding milk for domestic 
purposes, which are the subjects of M, mdiiensis infection. 

4. Prohibition of the entry of goats into Valletta and fortified 
cities, and into barrack squares, etc. 

II. PcUliution, 

1. Popular education with regard to the infective character of the 
milk from certain animals with instructions as to boiling the fluid 
to destroy its noxious character; also with regard to the infective 
nature of milk products from such animals {e.g., cheese, ice-cream). 

2. Absolute prohibition, by orders from the Admiral commanding 
the Mediterranean Fleet and the officer commanding the land forces, 
of the purchase and consumption of native fresh milk (or of milk 
products, such as cheese, ice-cream, etc., prepared from native milk) 
by either officers or men, provision being made for definite penalties 
in the event of disobedience. 

3. The official supply, by importation, of a sufficiency of reliable 
brands of preserved and condensed milks to the naval, military, and 
civil hospitals, and to the various canteens and messes. 

III. Eradication, 

1. Compulsory registration (by Ordinance) of every owner of one 
or more goats, oows, ewes, milch asses, etc., whether kept for the 
purpose of trade or otherwise, and of every breeder of such animals, 
and the granting of a metal badge bearing a specific sign or number 
for each animal, such badge to be securely attached to the animal to 
which it has been assigned, provision being made for the imposition 
of penalties for disregard or evasion of the enactments of this 
Ordinance. 

2. Strict enforcement of Ordinance No. Ill of 1904, Cap. II, 
Section 5, Articles 79, 82, 83, and of the penalties referred to in 
Cap. IV, Articles 161 165, 174 (by Ordinance). 



Digitized by VjOOQ IC 



Badeinoloffiml and Experimental Invest if jot iom, 1906. 187 

3. The interpolation of the words ** milch goat, milch ass, ewe, or 
other animal yielding milk for domestic purposes'' after the words 
" milch cow," in every article of the Fifth Section of Ordinance No. Ill 
of 1904, where such words are needed to apply the provisions of the 
article to animals other than the milch cow; also the interpolation 
of "Mediterranean Fever" into Article 91 {b\ specifying certain 
infective diseases of animals; also the interpolation of the words 
" Mediterranean Fever " after the words " tuberculous disease " in 
Article 93, specifying powers of entry by sanitary officials, and of the 
words " or ice-creams " into Article 100 (2), specifying milk products 
to which the article is applicable. 

4. The establishment of small laboratories with an adjoining com- 
pound, equipped for the performance of the " Zammit " milk test and 
the segregation of infected animals in such districts as Zeitun, Zurrik, 
Gargur, Notabile, and Mellieha in Malta and Victoria in Gozo, each 
under the charge of a specially detailed medical officer of health, 
assisted by a sanitary inspector; the function of each district 
laboratory being to examine once in every two weeks a sample of 
milk from each milch goat, etc., within its district; to seize, to 
segregate, and to report to the Public Health Department such 
animals as yield a positive reaction, and to forward specimens of their 
milk for bacteriological examination, and on the removal of infected 
animals to supervise the disinfection, etc., of the premises from which 
the seizure has been made. 

5. On completion of proof that suspected animals are infected and 
infective, the Public Health Department shall seize such animals and 
dispose of them, either by slaughter and sale in the public abattoir, 
or otherwise, and compensate the owner according to a fixed scale to 
be subsequently determined. 

6. In the case of valuable animals, good milkers and in good 
condition, the owner shall be compensated as in 5, and the animals 
retained alive for breeding purposes at an experimental station 
situated, say, at Ghain Tuffieha. 

7. Immediately after the birth the offspring of infected dams shall 
be removed and subsequently fed on milk from healthy animals or on 
Pasteurised milk from infected animals. 

8. As the infected animals are replaced by healthy ones they may 
be fattened up, slaughtered at the public abattoir, and the flesh sold. 

9. Finally, experimental treatment by M, melitensis vaccine, on 
the lines indicated in this Report, should be carried out on a large 
scale, and its potentialities estimated. 



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THE ADMIRALTY, THE WAE OFFldp, AND 
THE CIVn. GOVERNMENT OF MALTA, 

FOR THE INVESTIGATION OF 

meditereanean fever, 

UNDER THE SUPERVISION OF AN 

ADVISOEY COMMITTEE 

OF 

THE ROYAL SOCIETY. 



PART VII. 



^ LONDON: 
HARRISON AND SONS, ST. MAJBTIN'S LANK, 

PBIirTKBS IN OBDIKABT TO HIS MAJB8TY. 

PTnce Five Shillings. 

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INTRODUCTION. 

In the introductions to Parts I and III the history of this investiga- 
tion was related from its commencement in June, 1904, until July, 
1905. 

The Commission appointed to continue the work during the summer 
of 1905 consisted of Lieut.-Colonel A. M. Davies, R.A.M.C., Major 
W. H. Horrocks, RA.M.C., Staff-Surgeon E. A. Shaw, R.N., Dr. T. 
Zammit, Board of Health, Malta, and Captain J. Crawford Kennedy, 
R.A.M.C. 

Lieut.-Colonel Davies left Malta for England on September 24, and 
Major Horrocks for Gibraltar on October 14, 1905, while Messrs. Shaw, 
Zammit, and Kennedy continued the investigation during the following 
winter. The results of the work of the Commission during 1905 are 
published in Parts III, FV, and V. 

At a meeting of the Mediterranean Fever Sub-Committee held on 
February 25, 1906, it was decided to continue the work during the 
ensuing summer, and, as Messrs. Davies, Horrocks, and Shaw would 
not be available, that Major T. McCulloch, R.A.M.C., Major J. C. Weir, 
R.A.M.C., Major J. G. McNaught, RA.M.C, Staff-Surgeon F. H. A. 
Clayton, R.N., and Dr. J. W. H. Eyre, M.D., Bacteriologist to Guy's 
Hospital, be appointed to the Commission in addition to Captain 
Kennedy and Dr. Zammit. 

Colonel D. Bruce, R.A.M.C, Chairman of the Sub-Committee, was 
also requested to proceed to Malta to introduce the new members to 
the work. He arrived in Malta on April 14, 1906, and work was at 
once begun on the lines laid down by the Sub-Committee in their 
memorandum dated February 23, 1906. He left for England on 
May 5. 

Dr. Eyre and Major McNaught remained in Malta until September 2, 
and Staff-Siffgeon Clayton, Majors McCulloch and Weir, and Captain 
Kennedy until the end of that month. 

The work done in the summer of 1906 is embodied in Parts V, VI, 
and VII :— 

Part VI. — "Report upon the Bacteriological and Experimental 
Investigations during the Simuner of 1906," by J. W. H. 
Eyre, M.D., Major J. G. McNaught, R.A.M.C., Captain J. C. 
Kennedy, RA.M.C, and Dr. T. Zammit. 

Part VII.— "Epidemiological Work in 1906: (a) Naval," by Staff- 
Surgeon F. H. A. Clayton, RN. ; " (b) Military and Civil," by 
Majors T. McCulloch and J. C. Weir, R.A.M.C. 
(2089) b 2 



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4 I)Urod7tdio7i, 

The Bacteriological Report (Part VI) discusses infection by goats' 
milk, conveyance by mosquitoes and other blood-sucking insects, 
infection by contact, prophylactic vaccination, and clinical observa- 
tions. Dr. Eyre and his colleagues sum up their results by saying that 
the ingestion of infective articles of food, mainly milk, is the most 
common path of infection by Micrococcus melitensis in man ; that the 
next common path of infection is by subcutaneous inoculation during 
the handling of infective material, usually milk, and that more rarely 
infection may occur as the result of contagion, or possibly through 
convection by means of blood-sucking insects. 

The Epidemiological Reports (Part VII) go fully into the occurrence 
of cases of Mediterranean Fever in ships, barracks, and hospitals, with 
statistics relating to the incidMice among various classes, effect of age 
and sex, residence, climatic conditions, etc., and also give a detailed 
account of the result of preventive measures instituted in the middle 
of 1906. 

The epidemiologists are led to believe that quite 70 per cent, of the 
cases are due to the ingestion of goats' milk. They also believe that 
it is probable that the disease is acquired through infected milk, or, less 
often, urine, coming in contact with breaches of the surface, and so 
inoculating the disease. In their opinion, ordinary contact with the 
sick, conveyance of infection by biting insects, house-flies, dust, drain 
emanations, food (other than milk), and water play a very subordinate 
part, if any, in setting up Mediterranean Fever in man. 

The exceUent results following the preventive measures directed 
against the use of goats' milk in barracks and hospitals also point to 
milk being the chief factor. 

Among the soldiers this resulted in a diminution of about 90 per 
cent. For example, in the second half of 1905 there were 363 cases of 
Mediterranean Fever, whereas in the corresponding part of 1906 there 
were only 35 cases. Among the sailors there was also as marked a 
fall in the number of cases. Very remarkable is the history given by 
Staff-Surgeon Clayton in regard to the Naval Hospital at Malta. This 
building had a bad reputation, as one-third of the cases of fever 
occurring in the fleet at Malta could be traced to residence in this 
hospital, either as patients suffering from other diseases or among the 
nursing staff. The goats supplying the hospital with milk were 
examined, and some 10 per cent, of them were foimd to be passing 
Micrococcus melitensis in their milk. About the end of June goats' 
milk was forbidden, and since then not a single case of Mediterranean 
Fever has occurred in, or been traced to residence in, this hospital. 

Taking all the facts and arguments into consideration, it would 
appear that this Commission has been successful in discovering the 
main source of infection of Mediterranean Fever. This source is the 
Maltese goats, some 20,000 in number, half of which are affected by 



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Introdtidion, 5 

Mediterranean Fever, and one-tenth are constantly passing the parasite 
of this disease in their milk. If this source of infection is removed, 
in all probability the fever will disappear completely from Malta. 

The special thanks of the Commission are due to His Excellency the 
Governor ; the Lieutenant-Governor ; Lord C. Beresford, Naval Com- 
mander-in-Chief ; Colonel Winter, A.S.C. ; Colonel J. G. MacNeece, 
R.A.M.C., P.M.O., Malta; Lieut.-Colonel J. H. Rhodes, RA.M.C. ; 
Lieut.-Colonel R. Jennings, R.A.M.C. ; Major G. S. Crawford, 
R.A.M.C. ; and Captain £. Ryan, R.A.M.C. ; and the officers of the 
Royal Army Medical Corps generally; Deputy-Inspector-General 
Bentham, R.N., and officers, Bighi ; the Hon. L. Gatt, C.M.G. ; the 
Hon. Sir R Micallef, K.C.M.G., the Governor, Detention Barracks ; 
Mr. A. M. MacFarlane, Government Veterinary Surgeon; Professor 
Samut and Dr. Portelli Carbone, of the Civil Hospital ; Dr. Caruana 
Scicluna, and Dr. A. Critien, Board of Health ; Drs. Said and Rutter, 
of the Government Medical Service ; Mr. T. Curmi, Superintendent of 
Police ; the Superintendent of the Civil Hospital ; Mr. Grout, of the 
American Consular Service; Fleet-Surgeon Hardie, of H.M. Dock- 
yard ; Professor Magro and Cyril Leach, Esq., of the Meteorological 
Department, University of Malta. 



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6 Major McCuUoch, Major Weir, and Staff-Surgeon Clayton. 



EPIDEMIOLOGICAL WORK IN 1906. 

By Major T. McCulloch, M.B., Major J. C. Weir, M.B., Royal 
Army Medical Corps, and Staff Surgeon F. H. A. Clayton, 
M.D., Royal Navy. 

(Received 25th January, 1907.) 



Introductory. 

As the result of a recommendation of the Sub-Committee of the 
Royal Society, one naval and two army medical officers were appointed 
to the Commission in 1906, to continue the investigation of the causation 
of Mediterranean Fever from the epidemiological side. Accordingly, 
the writers of this part of the Report arrived in Malta in April and 
worked there until October, a period which covers the season when the 
disease is most prevalent. 

Epidemiological work on behalf of the Commission was begun by 
Dr. R. W. Johnstone, of the Local Government Board, in the fever 
season of 1904, and it was continued by Lieut.-Colonel A. M. Davies, 
R.A.M.C., in the following year. Dr. Johnstone's Report gives such 
topographical details as are of importance in an epidemiological enquiry, 
together with a general sanitary survey of the Maltese islands, and he 
deals comprehensively with the prevalence of Mediterranean Fever 
among the civil, naval, and military sections of the population. 
Lieut.-Colonel Davies devoted most of his time to a critical study of 
the disease as it manifested itself amongst the troops and the military 
families constituting the garrison in 1905, and he also furnished a 
detailed report on the sanitary condition of the various barracks in 
which the troops are housed and of the hospitals in which their sick 
are treated. The ground was, therefore, cleared to a large extent by 
the work of both of those observers, and this Report should be read in 
conjimction vrith theirs, as there would be no object in repeating 
information concerning which there is nothing new to record. Some 
overlapping will, however, be unavoidable, as, for example, in bringing 
tables or other matter up to date. 

No limit was placed on the scope of the epidemiological work to be 
undertaken during the season of 1906, but we were aware that the 
Sub-Committee considered the following points as of special import- 
ance : — 

1. The early and careful study of each case of Mediterranean Fever, 
and its surroimdings. 



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Epiderwiological Work in 1906. 7 

2. The possibility of the conveyance of the disease to man by the 

use of goats' milk or its products. 

3. Mosquitoes, flies, or other insects as possible carriers of the 

disease germs. 

4. Facts bearing on the determination of the incubation period. 

As our work proceeded, other points came to the front, e,g,^ the 
question of place infectioi), the relation of simple continued and enteric 
fevers, the insidious nature of the onset of illness, etc. It early became 
evident that some attention to an analytical study of the statistical 
history of past years was essential, and that important information 
was to be obtained from comparison of the behaviour of the disease in 
other stations. Further, in our capacity of service medical officers, we 
were instructed to act in concert with the naval and military authorities 
regarding practical measures, such as the provision of isolation accom- 
modation for military cases, and in recommending the application of 
any additional preventive measures in relation to both army and 
navy, or the modification of any of those already in use, which the 
course of investigation might suggest. In addition to the investigations 
relating to the services, steps were taken for keeping up the observa- 
tions, commenced by Dr. Johnstone in 1904, as to the prevalence of the 
disease amongst the civil population. 

This Report will, therefore, be divided into the following parts : — 
I, Naval; n. Military; HI, Civil. Following Part III is a paper, 
contributed by Dr. A. Critien, of the Public Health Department, 
Malta, on goats' milk as a factor in the causation of Mediterranean 
Fever amongst the civil population. Finally, a general simimary has 
been drawn up, in which are given the conclusions drawn from a critical 
examination of the naval, military, and civil observations. 



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8 Major McCulloch, Major Weir, and Stafif-Surgeon Clayton. 

Division I.— NAVAL. 
By Staff-Surgeon F. H. A. Clayton, M.D., Eoyal Navy. 
SYNOPSIS OF CONTENTS. 
Bionov A. — EpiDiMioLoar ov Miditebbaitban Fbtbb nr thb Naty. 

PAOB 

L The oonneotion of attacks of Mediterranean Ferer with recent staj in 

the Eoyal Naval Hospital, Bighi 10 

(a) Mediterranean Feyer oocxuring in patients under treatment in 

hospital for other diseases 11 

Short histories of cases almost certainly contracted in hospital 12 

Oases with onset within eight days of discharge 17 

List of patients who hare actoaUy dereloped Mediterranean Feyer 

while in hospital for other diseases during 1905 — 6 18 

List of patients who developed Mediterranean Ferer within eight 

days of discharge after treatment for other disease 19 

Patients who dereloped Mediterranean Ferer at varying intervalB 

after discharge from Bighi 19 

Symptoms suggesting earlier infection 21 

Comparison of the incidence of the disease in persons who have 

been resident as patients in hospital within the preceding three 

months with those in whom no history of any connection with 

hospital could be obtained 22 

Description of Bighi Hospital 22 

Distribution of Mediterranean Fever cases in Bighi Hospital and 

effect of propinquity on other patients 25 

Relationship to the amount of susceptible and of infective material 

in hospital 26 

Meteorological conditions 38 

Belationship to type of disease for which the patient was originally 

under treatment 85 

Direct evidence with regard to mosquitoes 85 

Direct evidence with regard to milk infection 40 

(i) Mediterranean Fever occurring among the sick berth staff 44 

Proportion affected 44 

Average duration of residence previous to contraction 45 

Proportion in which various ratings are affected 45 

Belationship of attacks to duties 45 

Month of onset and proportion affected each year 52 

Description of quarters 53 

The outbreak among the staff in 1906 58 

Belationship to previous attacks of illness 55 

Facts elicited by study of individual cases in hospital staff 55 

Milk history 56 

Mosquitoes, contact, hand disinfection 56 

(c) Mediterranean Fever occurring in the other residences and 

quarters 56 

((Q Mediterranean Fever occurring in the hospital ship *' Maine " 57 

Accommodation and routine 57 

Milk supply 58 

Employment 58 



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Epidemiological Work in 1906. 9 

PAOB 

(0) Summarj of the evidenoe obtained in connecUon with the contrac- 
tion of Mediterranean Fever in the Bojal Naval Hospital, Bighi 59 
II. Analysis of cases showing no very definite connection with residence in 

Bighi 60 

III. Occurrence of Mediterranean Fever among officers as compared with 

men 60 

IV. The connection of outbreaks with docking 63 

Description of docks and surroundings 68 

Possible reservoirs of infection in the neighbourhood 63 

Evidence of the presence of mosquitoes 64 

Latrines 66 

Possibilities of infection apart from convection by biting flies 66 

Facts shown by the returns of docking referred to 66 

Influence of previous hospital residence 66 

V. The possibility of connection between attacks of Mediterranean Fever 

and sexual intercourse with infected persons 68 

Facts elicited from the study of individual cases 70 

SeCTIOIT B. — PbBTBKTITB MBABlTBBfl INSTITirTBD AaAIVST MbDITBBBAVBAK 

Fbteb in thb Natt. 

I. Methods of prevention undertaken in 1906 70 

Protection from the attacks of mosquitoes 70 

Disinfection of patients* effects 71 

Control of milk supplies 71 

Milk in the Fleet 72 

Ice creams 78 

II. Incidence of Mediterranean Fever since the foregoing measures were 

instituted 74 

Incidence in the Fleet 74. 

Incidence among persons constantly resident in Malta 74 

Incidence in Bighi Hospital 76 

Conclusion 78 

SbCTIOV C— PeBSOKAL iNTBSTiaATIOVS. 

I. The prevalence of Mediterranean Fever in separate ships during 1906 

Battleships 78 

Cruisers 86 

Destroyers 90 

II. Facts elicited by the study of individual cases 93 

Time on station 98 

Previous service on station 94 

In dock or alongside dockyard. 94 

Cases occurring in the Service afloat 95 

Exposure to infection ashore 100 

Facts pointing to the contraction of the disease in Malta rather 

than elsewhere 102 

Dockyard. Civilian, English 103 

„ „ Maltese 106 

III. A more complete history of the outbreak of Mediterranean fever on 

board the S.S. " Joshua Nicholson" 107 

History of the j^oats Ill 



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10 Major McCulloch, Major Weir, and Stafif-Surgeon Clayton. 

The incidence of Mediterranean Ferer among tiiose wlio partook of 

the milk 112 

In the w. << Josboa Nicbolaon " 112 

At Antwerp 112 

In the 8.8. " St. Andrew" 116 

In America 116 

Epidemiological obserrations 117 

Duration of period between ingettion of goats* milk and the 

development of symptoms 120 

The epidemiological work which has been undertaken this year 
may be divided into three sections : (a) Historical ; (b) Preventive 
measures and the incidence of the disease since their institution ; and 
(c) Personal investigations, including a study of the disease as it baa 
occurred in separate ships, and of the facts elicited from enquiry into- 
individual cases. 

Sbotion a.— EPIDEMIOLOGY OP MEDITERRANEAN FEVER IN 

THE NAVY. 

In connection with the epidemiological section it was felt that 
where, as in sea-going ships, the environmental conditions were so> 
perpetually varying, any attempt to study the history of the disease 
as it has occurred in separate ships would not repay the expenditure 
of time. Presence in or absence from Malta, the time of year>. 
position in the harbour, and so on, are all factors that have to be 
reckoned with, and about which it is impossible to obtain accurate 
information. 

Accordingly, attention has been concentrated upon the connection 
of Mediterranean Fever with conditions which are well known ta 
influence causation or with considerable reason suspected to do so, 
and about which definite information can be obtained, and the study 
of the incidence of the disease in separate ships has been confined ta 
the present year when the details of movements and of other conditions 
are available. 

I. — The Connection of Attacks of Mediterranean Fever with 
Recent Stay in the Royal Naval Hospital, Bighi. 

First and most important of the factors which are believed to have 
an influence in causation is : — 

The connection of attacks of Mediterranean Fever with recent stay 
in the Royal Naval Hospital, Malta, either while suffering from other 
illness or as a member of the hospital staff. 

This question has been investigated for the period from January, 
1902, to the present year (1906), since this provides a quinquennial 
period, and one, moreover, in which the agglutination reaction and 



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Epidemiological Work in 1906. 



11 



the estimation of the dilution has been made use of as a routine 
method of diagnosis, the records being therefore correspondingly 
reliable. 

(a) As Patients under Treabneni for other Diseases. 

The following table shows that every year a very considerable 
proportion of the naval cases, usually about one-third of those which 
come under treatment, have, at some time within the three months 
preceding onset, been in Bighi suffering from other illness.* It was, 
of course, necessary to investigate this previous hospital history for 
some definite period only, and three months has in consequence been 
taken as the limit, chiefly because it was foimd to include practically 
all the cases, as is shown in Table II. 

Table I. — Showing the Proportion of Gases dealt with each Year which 
have been under Treatment in Bighi with other illness during the 
three months preceding onset. 



Year. 


Where under treat- 
ment. 

InBiffhi 


Total cases dealt 

with, excluding 

relapses. 

293 

265 

259 

241 
46 

287 

120 
55 

175 

1279 


Proportion under 

treatment in 

preceding 3 months. 


1902 
1903 
1904 
1905 

1906 


83 


Elsew lere 




In Bighi 


77 


Klsewnere 




In Bighi 


96 


£lsewnere 




In Bighi 




Elsewhere 




Total 


137 


In Bighi 




Elsewhere 





Total 


79 




Grand total 


471 



A few cases (21 in number) who were previously in hospital for 
illness which at the time was considered to be other than Mediterranean 
Fever, and was so classified, have been omitted from this table, either 
on account of the presence of a doubtful reaction during this first 
stay or because the subsequent history of the case has given reason 

• The B. N. Hospital is situated at Bighi, and will be referred to throughout 
this paper under that name. 



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12 Major McCulloch, Major Weir, and Staff-Surgeon Clayton. 

to doubt the accuracy of the original diagnosis. Moreover, in about ' 
a dozen of those included in Table I, the previous illness must be 
regarded as suspicious, although there was not sufficient evidence to 
justify amendment of the original diagnosis ; but, with these excep- 
tions, the patients may reasonably be looked upon as suffering from 
other illness. In deciding whether or not a previous illness was the 
first manifestation of Mediterranean Fever, one has to take into 
account the fact that it is not uncommon for the initial symptoms to 
reflect the previous medical history. Thus, in a case preceded by 
otorrhoea, the onset was signalised by a recurrence of the ear discharge ; 
a second, with a history of head injury and resulting frequent 
headache, started with an epileptiform seizure ; and records of more 
than one abscess or other surgical case have been met with where 
local recurrences accompanied the first signs of illness. After all, 
it is not extraordinary that a generalised infection should proceed 
along the line of least resistance. 

The consistency with which so large a proportion of Mediterranean 
Fever cases present a similar history for a series of years disposes 
of the possibility of mere coincidence, but the following facts are also 
strongly suggestive that the majority of these cases were actually 
contracted in Bighi. 

As is shown in Table II, a very considerable proportion may be 
regarded as almost certainly contracted there, and this, together with 
the enormous incidence among the sick berth staff constantly resident 
(vide p. 44), shows that the risk of infection is unusually great, and 
argues for a similar causation in the other cases. 

A list, giving a short history of cases almost certainly contracted 
in hospital, follows. In this no patient has been included in whom 
there is not a history of at least 21 day^' residence, with other illness 
before onset (the majority being far longer), or, among those who 
have been discharged, where the onset has occurred more than eight 
days after leaving. For 1905 and 1906 lists have kindly been 
provided by Staff-Surgeon Whiteside, but for previous years it has 
been necessary to consult the case sheets, and, owing to the longer 
limit of time, the number is smaller than that given by Dr. Johnstone 
in Part II of these Reports. If anything, therefore, it is probably 
under-estimated. 

List of Cases almost certainly Contracted in Hospital. — 1. W. P., Str. — 
Admitted to B 2 Ward on NoTember 20, 1901, with renereal bubo, mass of protruding 
glands and slight temperature. G-lands removed November 23 and temperature feU 
to normal and remained tiU February 20, 1903, 92 dajs after admission, when he 
had nausea, vomiting, and pyrexia for three days. Second rise of temperature. 
May 4, and on the 12th he reacted. 

2. F. J., Str.— Admitted to E 1 Ward on January 29, 1902, with a broken down 
bubo. Operation February 26 and temperature normal till March 15, 46 days after 
admission, when he had temperature, anorexia, and pain in knee for three days. 



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Epidemiological Work in 1906. 13 

Seoond operation April 13 followed by temperature and headaohe for 10 days. On 
May 81 fever returned and his serum reacted 1 in 40. 

3. T. Q., Sigln.— Admitted to E 1 Ward on February 18, 1902, for hernia, for 
whioh operation was performed on 27tli. He was well till April 18, 65 days after 
admission a^d when wound was healed. He then developed malaise and pyrexia 
and gave reaction 1 in 40 on April 17. 

4. D. N., Lg. Seaman.— Admitted to £2 Ward on February 26, 1902, with 
gonorrhoea. No developments till May 6, 70 days after admission, when he had 
headache and pyrexia and gave a positive reaction on May 18. 

5. T. T., A.B.— Admitted to E 1 Ward on June 27, 1902, with simple fracture of 
both bones of leg. On July 19, coincident with an abscess of the leg and falling on 
incision of latter he developed fever and on August 4 this once more occurred. On 
August 24, 68 days after admission, he developed high temperature and headache, 
and on the 26th gave positive reaction. 

6. E. H., Petty Officer.— Admitted on May 81, 1902, to El Ward vnth a simple 
fracture of femur. Did well till August 27, 89 days after admission, when he had 
fever and headache for three days. Normal till October 28, when he had a 
recurrence of symptoms and reacted 1 in 60. 

7. E. M., Petty Officer.— Admitted on July 29, 1902, to El Ward with a 
compound fracture of lower third of femur, involving luiee joint. By August 12 the 
wound was healed and he was up on crutches in September, but on October 11 he 
developed temperature and headache and reacted next day. 

8. A. H., Yeoman of Signals. — Admitted to Zymotic Block on August 4, 1902, 
with a typical attack of enteric, giving negative reaction with MioroeoocuM nuU- 
ieiuis. His temperature was normal by September 2, and so remained till 
October 16, 78 days after admission, when he had headaohe and persistent fever. 
Marked positive reaction on October 22. 

9. P. H., Pte.— Admitted to El Ward on August 27, 1902, with a lacerated 
wound of thumb. Three days' temperature and headaohe on September 28, 29 days 
after admission. Wound was healed by October 18 and on the 20th he had a 
return of symptoms and reacted 1 in 60 on the 22nd. 

10. C. A., Signal boy.— Admitted on September 5, 1902, to E 1 Ward with a 
compound fracture of leg. On October 22, 47 days after admission, he developed 
fever, headache, etc. 

11. Q. W., G-.M.A. — Under treatment in ship for months for eczema and was 
admitted on October 8, 1902, to El Ward. On November 14, 86 days after 
admission, he developed headaohe and fever and reacted on December 22. 

12. W. E., Cook's Mate. — Admitted on December 26, 1901, with multiple fracture 
of jaw. Wired on 80th. Had abscess at angle, with some fever on Februaiy 6. 
On April 10, 107 days after admission, he had malaise, headache and fever and 
reacted on April 16, 1 in 40: 

13. W. S., Str.— Admitted to E 1 Ward on March 6, 1902, with hamorrhoids, for 
which operation on March 11. On April 6, 80 days after admission, he complained 
of vertigo and temperature rose on 9th. Reaction on April 17. 

14. H. T., Pte.— Admitted on June 30, 1902, to E2 Ward with acute gonorrhoea. 
On July 26, 27 days after admission, had headaohe and fever and reacted on August 8. 

16. E. M., Str.— Admitted on October 8, 1902, to E 2 Ward with gonorrhoea and 
epididymitis. On December 16, 76 days after admission, complained of abdominal 
pain and diarrhoea and had fever. He reacted on December 28. 

16. H. B., Petty Officer.— Admitted on December 6, 1902, to El Ward with 
multiple injury. On January 18, 1903, he developed headaohe and fever for a day 
or two, 89 days after admission, and on February 21 had a wave of fever with rigors, 
sweats, etc. 



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14 Major McCulloch, Major Weir, and Staff-Surgeon Clayton. 

17. C. C, Pto.— Admitted on December 6, 1902, to £ 1 Ward with a fracture of 
the leg. He did well till February 22, 1908, when he developed headache and fever, 
79 days after admission, and reacted 1 in 60 on the 24th. 

18. H. B., A.B.— Admitted on December 26, 1902, to E 1 Ward with fracture of 
jaw and other injuries. On May 21, 146 days after admission, he had rise of 
temperature and rheumatic pains and gave a positive reaction on the 27th. 

19. A. B., Petty Offioer.—Admitted to W2 Ward on November 27, 1902, with 
sciatica. Disease had persisted for months without other symptoms and there was a 
strong rheumatic history. On December 28, 29 days after admission, he developed 
fever and headache and reacted on December 81. 

20. E. Y., Pte. — ^Admitted on November 24, 1902, with tumour in iliac region and 
symptoms of appendicitis. Had one or two days' malaise and pyrexia on 
February 10, 78 days after admission, and on the 2l9t a second wave with enlarged 
spleen. Iliac region again tender. 

21. S. L., Str. — Admitted to E 1 Ward on January 12, 1908, with simple fracture. 
About February 6 had pyrexia lasting five days, with painful sweUing of jaw which 
was incised. Tonsils swollen. This was 25 days after admission, and 48 days later 
he had pyrexia and recurrence of swelling. Positive reaction five days after. 

22. P. P., Maltese Shipwright.— Admitted to El Ward on February 2, 1908, with 
a compound dislocation of the thumb. On March 9, 85 days after admission, 
had a rise of temperature, malaise, and vertigo. Reacted on March 14. 

23. T. E., Str.— Admitted to W2 Ward on March 28, 1903, with hematuria and 
dullness in left flank. Temperature normal. On April 28, 81 days after admission, 
developed fever and headache. Oave definite reaction on May 29. 

24. I. J., Str.— Admitted to El Ward on April 9, 1903, for hernia. After 
operation on May 7, 29 days later, the temperature never fell properly and on 
May 20 blood yielded a positive reaction. 

25. H. L., Ord. Seaman.— Admitted to W 2 Ward on March 31, 1903, with pain 
over liver and jaundice. This had been preceded by inflammation of scrotum and 
liver enlargement followed. Temperature normal and steady improvement till 
April 21, 22 days after admission, when he developed temperature with pain in right 
flank and all over. Reacted on April 26. 

26. W. S., Ord. Seaman.— Admitted to W 2 Ward, after several attacks of 
tonsilitis, for operation. Removed on April 18. On April 24, 24 days after 
admission, developed fever and headache. Reacted on May 11. 

27. P. W., A.B.— Admitted to El Ward on June 8, 1908, with ischio-ieotal 
abscess. Steady improvement after operation, but on August 3 headache and 
diarrhoea began, and on August 10 his temperature rose and he reacted on the 16th. 
Onset 56 days after admission. 

28. J. M., Str.— Admitted to E 2 Ward on July 18, 1903, with a suppurating 
patellar bursa. On August 11, 24 days after admission, there was slight pyrexia 
of nine days* duration with no symptoms. September 8, fever of a week's duration. 
September 21, the femoral glands, which had become enlarged on August 3, were 
opened up. This was at once followed by a rise of temperature and a positive 
reaction was obtained two days later. 

29. W. F., Petty Officer.- Admitted to W2 Ward on May 1, 1903, with well- 
marked signs of pleurisy and pericarditis. By June 3 was ^irly weU, but on this 
date, 34 days after admbsion, a slight rise of temperature occurred which persisted, 
and on June 23 he complained of pains all over. June 25 reacted 1 in 60. 

80. E. A., Yeoman of Signals.^Admitted to C Ward on November 8, 1903, with 
hernia, for which operation performed. Healed by November 19, but on Januaiy 9, 
1904, 67 days after admission, he had sudden rise of temperature and reacted next 
day 1 in 200. 



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Epidemiological Work in 1906. 15 

31. J. F. C, G.M.A.— Admitted to E Ward on November 26, 1903, with 
otorrboea, temperature normal. Quite well till February 10, 76 days after admission, 
when he developed headache and fever. Reacted on February 12, 1 in 60. 

82. T. B., Ord. Seaman.— Admitted to E Ward on December 5, 1903, with 
discharge from ear. No temperature except 99°'2 on January 14, 1904, until 
January 31, 57 days after admission, when he had vomiting, headache and fever. 
Reacted next day 1 in 200. 

33. E. S., Str. —Admitted to E3 Ward on December 8, 1903, with enteric fever. 
Temperature fell about end of January, 1904, and he did well till February 24, 
78 days after admission, when had rise of temperature. Reacted next day 1 in 60. 

34. A. S., Ord. Seaman.— Admitted to £ Ward on November 7, 1903, with ulcers 
of legs and enlarged glands. He was well till April 2, 146 days after admission, 
when he had rigors, fever and headache. Reacted next day 1 in 60. 

36. A. L., Able Seaman.— Admitted to B Ward on December 16, 1903, for 
gonorrhosal rheumatism. Temperature rose about January 16, 1904, 82 days after 
admission, and a positive reaction was obtained the same day. 

36. F. S., G.M.A.— Admitted to C Ward on December 16, 1903, with a contusion 
of thigh. Symptoms of fever first appeared on February 16, 1904, 62 days after 
admission, and a positive reaction was obtained the same day. 

37. T. D., Able Seaman.— Admitted to B Ward on December 22, 1903, with 
gonorrhcea. No symptoms till January 14, 1904, 24 days after admission, when he 
developed fever, headache and shivering. This passed off rapidly, but recurred on 
February 10. Reaction present on January 14. 

88. C. B., Stoker. — Admitted to C Ward on January 4, 1904, with a compound 
fracture of leg. Doing well till February 13, 40 days after admission, whein there 
was a rise of temperature and headache for two days. This recurred on 
February 26 and reaction was present. 

39. W. F., Able Seaman. — ^Admitted to E Ward for haemorrhoids on January 19, 
1904, which were removed on January 23. On February 13, 26l days after admission, 
there was a rise of temperature and headache, and the blood reacted in a dilution of 
1 in 100. 

40. J. N., Private. — ^Admitted on January 21, 1904, to Ward for hernia, for 
which an operation was performed on January 27, the wound healing nicely. On 
February 27, 37 days after admission, there was a rise of temperature and headache, 
and the blood was found to react 1 in 10. 

41. J. R., Private. —Admitted on January 26, 1904, to C Ward with a fracture of 
olecranon. On February 17, 24 days after admission, he developed headache and 
temperature, and gave a positive reaction next day. 

42. C. S., Stoker. — Admitted to B Ward on April 7, 1904, with primary syphilis. 
Was all right until May 21, when he complained of headache and temperature rose. 
This was 44 days after admission, and three days later his blood gave a positive 
reaction. 

43. E, J. S., Able Seaman.— Admitted on May 23, 1904, to Wl Ward with well- 
marked attack of appendicitis and negative reaction. Was convalescent by June 24, 
but on July 6, 44 days after admission, he developed headache and showed a positive 
reaction. 

44. M. H., Petty Officer.— Admitted on July 10, 1904, to A Ward with 
gonorrhcea. No symptoms till August 30, 61 days after admission, when he 
developed a temperature and headache. First reacted 1 in 300 on September 20. 

45. B. M., Ordinary Seaman.— Admitted to E Ward on February 27, 1904, with 
rectal abscess. Operation on February 27, and temperature fell at once. Did well 
tin April 19, 51 days after admission, when temperature suddenly rose, and a positive 
reaction was obtained next day. 



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16 Major McCulloch, Major Weir, and Stafif-Surgeon Clayton. 

46. D. M., Petty Officer.— Admitted on March 10, 1904, to Ward W 1 with 
definite signs of tubercle, T. B., in sputum. Was doing well and gaining weight, but 
about April 19, 40 dajs after admission, got rise of temperature and hradaohe* 
FositiTe reaction on April 25. 

47. T. D., Private.— Admitted on July 11, 1904, to Ward Wl with well-marked 
symptoms and signs of pericarditis. This cleared up, but temperature began to rise 
about August 4, 24 days after admission, and from that time he had irregular 
pyrexia. First reacted on October 8. 

48. B. B., Fitter.— Admitted on September 7, 1904, to A Ward with chancroid 
and bubo. On December 6, 90 days after admission, developed headache and high 
temperature. Reacted next day. 

49. P. S., Able Seaman. — Had had a non-venereal bubo in his ship since June 
and was admitted with it to hospital on October 1 to I> Ward. Glands extirpated 
on October 18, but no symptoms till November 23, 53 days after admission, when 
wound had healed. Then headache and rise of temperature and positive reaction. 

50. A. H., Able Seaman. — Sick on board ship and in " Maine ** since August 22 
with a bubo and admitted to hospital on October 1 to I> Ward. No symptoms till 
November 23, when pain in back, followed by headache and fever, 54 days after 
admission. Positive reaction two days later. 

51. C. H., Stoker.— Admitted on October 1, 1904, to D Ward with disease of ear. 
No other symptoms till November 12, when headache and rise of temperature. 
Positive reaction four days later. 

62. T. B., Stoker.— Admitted to W4 Ward on October 1, 1904, with signs of 
phthisis, no temperature, but history of h»moptysis. On November 17, 48 days 
after admission, developed chills, rise of temperature and so on, and gave a positive 
reaction on November 22. 

58. J. McG-., Stoker.— Admitted to A Ward on October 12, 1904, with gonorrhoBa. 
On December 2, 51 days after admission, complained of headache and nausea, and 
had rise of temperature. Reacted on December 4. 

54. C. B., Able Seaman.— Admitted! to D Ward on October 28, 1904, with a 
simple fracture of leg. Began to feel ill about December 25, 57 days after 
admission, and first reacted on December 27. 

55. B. I., Lg. Stoker.— Admitted to D Ward on December 4, 1908, with fracture 
of lower jaw. Wired on January 28, and on February 11 had swelling and 
tenderness at ankle and on next day fever and inflammation of pharynx and tonsil. 
Well by 18th, but had temperature again on February 21, and on April 2 had 
recurrence and gave positive reaction. First symptoms 70 days after admission. 

56. J. McC., Private.^Admitted to B Ward on Januaiy 12, 1904, with syphilis 
primary. Doing well till February 6, when had headache and rise of 
temperature, 25 days after admission. Beacted five days later. 

57. G^. S., Stoker.— Admitted to E Ward on December 9, 1908, with an abscess of 
the chest wall. Improved greatly and vras all right till January 24, 46 days after 
admission, when he developed sickness and fever. Beacted on February 11. 

58. £. H., Able Seaman. — From October 17 to November 18, on board, sick with 
oedema of tonsils and was admitted on November 19, 1904, with well-marked 
diphtherial paralysis. Had one day's rise of temperature on November 21, but was 
then normal till December 24, 35 days after admission, when he developed fever 
and general pains and reacted on January 14. 

59. T. R., Stoker.— Admitted to C Ward for hernia on October 11, 1904, and had 
operation on October 15. On December 3, 53 days after admission, developed high 
temperature and headache, and reacted on December 5. 

60. W. W., Able Seaman. — ^Admitted to sick list on November 6 with bronchitis, 
and said he had night sweats, but no temperature at any time. Admitted to W 1 



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Epidemiological Work in 1906. 17 

Ward on NoTember 22, 1904, and had similar STmptoms in hospital until 
January 21, when he developed headache, tempeiature and pains, 60 dajs after 
admission. Beacted on January 28. 

Cases toith Onset within Eight Days of Discharge. — 1. E. Q-., Boy. — ^Was under 
treatment from February 28 to April 17, 1902, with abscess, and onset occurred five 
days after leaving. 

2. A. M., Stoker.— Was under treatment in E 2 from April 10 to June 2, 1902, 
for scabies, and onset was seven days after leaving. 

8. E. E., Chief Stoker. — Was under treatment for internal hemorrhoids from 
June 11 to July 29, 1902, in £ 1 Ward and symptoms probably began two days 
before leaving, but case is a little doubtful. 

4 W. T., Chief Stoker.— Under treatment in E 1 Ward from May 20 to July 24, 
1902, for hernia. Symptoms began at once on discharge. 

5. W. B., Able Seaman. — Under treatment in W 1 Ward and afterwards Zymotic 
from August 1 to October 8, 1902, with enteric. Onset the day following 
discharge. 

6. G-. H. D., Able Seaman. — Under treatment in Zymotic Ward for enteric fever 
from August 1 to October 17, 1902. Onset the day after discharge. 

7. A. F., Able Seaman. — Under treatment in El Ward from October 10 to 
November 21, 1902, with fracture of jaw, and became iU. at once on leaving 
hospital. 

8. W. H. D., Stoker.— Under treatment in B Ward from May 10 to July 6, 1908, 
with syphilis primary, and symptoms began eight days later. 

9. Mr. J. H., Lieutenant. — Under treatment in C Cabin from November 1 to 
November 25, 1903, with injury to knee, and symptoms began the day previous to 
discharge. 

10. F. P., Ordinary Seaman. — Under treatment in A Ward from September 28 to 
December 16, 1903, with syphilis primary, and was never well after discharge. 

11. F. C, Able Seaman. — Under treatment in D and C Wards from September 10 
to October 81, 1904, with operation for hanmier toe, and developed symptoms four 
days after discharge. 

12. W. O., Stoker.— Under treatment in B Ward from October 1 to November 18, 
1904, with syphilitic bubo, and developed symptoms four days later. 

13. P. C, Stoker.— Under treatment in B Ward from October 12 to November 18, 
1904, with chancroid, and developed symptoms eight days afte/ discharge. 

14. Mr. H. L. D., Commr. — In C Cabin from November 14 to November 28, 
1904, with fissure of anus, and developed Mediterranean Fever seven days later. 



(2089) n 

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18 Major McCulloch, Major Weir, and StaflF-Surgeon Clayton. 



List of Patients who have actually developed Mediterranean Fever 
while in Hospital for other Diseases during 1906-6, given by 
Staff-Surgeon Whiteside. 



Name. 



Kiting 



Wards. 



DiBease on 
don. 



Date of 



OnMt. 



Inteiral 
in days. 



W.B. 

J.H. 

J. M. 
W.W. 
H. M. 

H.H.M. 

W.B. 

E. T. 8. 

B.B. 

0. P. 

T. Q. 

A.O. 

J.H. 

S.S. 

J. L. 

H.W. 

E. B. 

J. A. 

T.L. 

T. B. 
A. J. 
W. T. 
W. K. 
P. S. 
H.B. 

8. T. a 



A. B. 
A. P. 
0. M. 

a.c. 

H.J. 



E.B.A. 

Ch. Stp. 

Str. 

S. Bait, 
a. M. A. 

Pte. 

a.M.A. 
Lg. Sn. ' 
A.B. 

0. P. O. 

Str. 
A.B. 

Str. 
A. B. 

Str- 
C. crew 

A. B. 

Lg. Sn. 
Pte. 

Pte. 

Pte. 
A.B. 
A. B. 

Str. 
Lg. Str. 

Pte. 



Str. 
Str. 
Str. 

Signl. 
Str. 



/F 

ID, Feb. 7 

/F 

\D,Feb.7 

A 

E4 

B 

fWl 

-^ W 2, Apr. 26 
LW I. May 16 

Af aboTe 

Af above 

D 

;o 

I D, Apr. 24 ... 



W2 

D 

D 

A 

C 

C Zymotic 

-^ E.Aug. 8 ... 
If, Aug. 7 ... 

C 

iF/NoTl'e!!!;!! 

A 

A 

B 

F 

B2 

E2 

fB 

< F, Jan. 30 ... 

lA, Feb. 19 ... 

fA 

^ F.Feb. 9 ... 

La, Feb. 19 ... 

A 

fB 

< F, Jan. 10 ... 
La, Feb. 19 ... 

;a 

IB, Feb. 19 ... 

/B 

1a, Mar. 23 ... 



V DiBcase of skin 

\ n bone 

Syphilis, prim. , 
Enteric fever ... 
Syphilis, prim. | 



Jan. 26 



V Pneumonia . 



Heart disease.. 
I Abscess 

\ Fractured jaw 

Hernia 

Laiyngitis 

Abscess 



See. gonorrhoBa ' 
Fracture, Potts*; 



Mar. 8 

,, 16 
„ 20 

Apr. 15 

,. 14 

' „ 1* 

,. 17 

„ 17 

' „ 20 

29 

29 

1 

4 

21 



May 



I Scarlet fever ... June 7 



Varix 

\ Chancroid 



Syphilis, sec. . 
Chancroids .... 
Disease of eye. 
Bronch. asthma 

Bubo, venereal 



Syphilis, sec. ...' 

Gonorrhoea 

V Syphilis, prim. | 

i- GU>norrhGDa 



Aug. 29 

Oct. 10 

Aug. 28 
„ 28 
Oct. 1 
Nov. 9 
Oc 1 
Jan. 27 

» 27 

» 30 
Dec. 12 



Mar. 10 

Apr. 12 

May 20 

„ 4 
June 1 



May 19 

„ 28 
June 9 

May 31 

June 9 
„ 2 
„ 10 
» 9 
» 4 

July 5 

Aug. 7 
Sept. 20 



PIOV. 

Oct. 


9 


>f 


11 


Nov. 


14 


Jan. 


7 


>t 


12 


Mar. 


6 


ii 


14 
19 



Feb. 5 
Mar. 6 

» 13 
„ 24 



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Hpidemiological Work in 1906. 



19 



List of Patients who developed Mediterranean Fever within Eight Days 
of Discharge after Treatment for other Disease during 1905-6. 



Name. 


Bating. 


In hospital 
preTioufllj. 


Wards. 


Diaease. 


Date of 

onset. 


Intenral 
in days. 


P. D. 


O.S. 


Feb. 16 to Apr. 17 


C 


Hernia 


Apr. 25 


8 


W.L. 


A. B. 


Mar. 8 ,, May 9 


E4 


Enteric 


May 11 


2 


G. B. 


Sir. 


May 26 „ July 20 


Wl 

E, June 21 


Colitis 


July 24 


4 


J.MoL. 


A.B. 


Aug. 26 „ Oct. 18 


A 


Chan, 
oroids 


Oct. 21 


8 


A.M. 


A.B. 


Apr. 26 „ MaySO 
Mar. 14 ,, June 2 


D 


Fracture 


June 8 


4 


J. M. 


Fitter 


D 


Wound 


May 28 


Nil 


E.B. 


B'kBmith 


Oct. 4 „ Not. 6 


B 


Hemor- 
rhoids 


Not. 9 


^ - 


H.F.C. A.B. 


Feb. 6 „ Apr. 26, 


r B \ 

A, Mar. 28/ 


Syphilis, 


Apr. 19 


3 


1 


1906 


sec. 







Paiienis who developed Mediterranean Fever at varying Intervals after 
discharge from Bighi, — In addition to the number included in this list, 
the onset of the disease in very many more occurs within a few weeks 
of discharge, and the number proportionately diminishes in accordance 
with the period which has elapsed since leaving. This is well brought 
out in the following table, and also points strongly to some etiological 
influence connected with Bighi : — 

Table II. — Showing the Numbers of Patients under Treatment for other 
Illness who developed Mediterranean Fever at varying intervab 
after discharge from Bighi. 



Year of onset 


. 1902. 

1 


1903. 


1904. 


1906. 


1906. 


Total. 


Within a month- 
While resident 


. 20 

•! 7 
. 18 
.1 22 
. 16 
. 6 


11 
2 
22 
25 
17 
6 


29 

5 

23 

80 

8 

1 


22 
7 
46 
45 
18 
4 


9 

1 

22 

30 

17 

4 


91 
22 
130 
152 
76 
20 


Within 8 days of discharge .. 

From 8 days to a month 

Between 1 and 2 months 










Total 

1 


. 88 


83 


96 


141 


83 


491-20 



Two possible explanations of this heavy incidence among patients 
recently discharged from Bighi must here be discussed. It has been 
argued, in the first place, that the debility produced by the illness 
which occasioned their stay reduces the natural resistance so much 
that they become a ready prey to the disease on subsequent exposure 
to infection. 

(2089) e 2 



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20 Major McCulloch, Major Weir, and Staff-Surgeon Clayton. 

Many facts, however, militate strongly against this hypothesis. For 
one thing, men in naval hospitals are not discharged until they are fit 
for duty, and in many cases a considerable interval of apparently 
perfect health has intervened between discharge and the onset of 
symptoms. Not only is this the case, but Table VII (p. 36) shows quite 
distinctly that liability is as great after non-debilitating disease such 
as otorrhoea, simple tumour, and so on, as after many more exhausting 
ailments. Again, attacks of Mediterranean Fever are by no means 
confined to patients who remain on the station; they occur with 
as great frequency among those invalided, who only leave hospital 
to embark for passage to England. Included in Table I are 25 
cases of this description during 1905-6, of which 11 had onset within 
a month of discharge, 12 within two months, and two within three 
months. Similarly, a few cases are included where, owing to the 
departure of the Fleet, patients have been sent to their ships while 
only convalescent, and have developed their symptoms without landing 
anyifhere. These show similar intervals. Under both these heads 
there are, of course, chances of infection in the ship, but it may 
at least be said that the possibilities are greatly lessened by the 
exclusion of shore infection. The results of enquiry into the move- 
ments of patients between discharge from hospital and onset of illness, 
as detailed at p. 100, may be referred to as illustrating that the 
opportunities of exposure ashore are, in the majority of cases, quite 
limited. 

A second attempted explanation for the special liability of hospital 
patients is that a latent infection is stirred into life by the debilitating 
influence of other illness. There are grounds for supposing that this 
does occur under certain circumstances, but in the present instance the 
evidence goes to prove that it is at least infrequent. The onset 
of disease would in that case correspond with the date of an injury or 
of an operation rather than occur long after the wound was healed. 
Besides, the proportion of officers (among whom the disease is far more 
common than among the men) who have been in hospital previously is, 
as will be seen later, a very small one. There seems no reason to 
suppose that debilitating circumstances should be more necessary to 
produce the disease in the seaman than in the officer. 

It will be seen in Table XXIV (p. 74) that since April, 1906, 
coincident with the cessation of the occurrence of cases while 
resident in hospital, or within eight days of discharge, there has not 
only been a fall in numbers in the fleet generally, but no single 
case admitted has given a history of hospital residence within the 
preceding three months. This is a very striking and significant fact. 

Nevertheless, to those who believe in an incubation period of 
rigidly definite duration, the acceptance of a relationship between 
residence in hospital and the occurrence of disease some six weeks to 



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Epidemiological Work in 1906. 21 

three months later will be difficult. It must, howeyer, be remembered 
that in experiments on animals the dosee used have been large, and 
the occurrence of infection has been mapped out by continual and 
systematic examination for agglutination and not merely by the onset 
of symptoms which, indeed, need not necessarily occur. It is tnie 
that man is said to be more susceptible than animals, but there 
is nothing in these experiments to negative the possibility that he also 
can become infected without the occurrence of very definite symptoms. 
The subject is discussed at greater length elsewhere. 

Symptoms Suggesting Earlier Infection. — With a view to the discovery 
of symptoms suggesting infection at an earlier stage in the history 
of these 471 cases, included in Table I, the hospital sheets of ^he 
majority of them were examined, with the result that about 47 were 
found to have exhibited symptoms at some time or another during 
their stay for which no very obvious explanation was forthcoming 
from their condition at the time. The following provide illustrative 
examples : — 

W. T., Cb. Str.—Admitted for hernia May 20, 1902. Operation May 28. 
Healed bj Jane 18 and allowed up. On July 8 had temperature and malaise 
lasting four days, with joint pains. Said be was neTer well after discbarge on 
July 24, and August 23 was {daoed on sick list. Admitted October 9. 

W. B., Str. — Admitted March 21, 1903, with gonorrhoea and perineal abscess. 
On incision of latter temperature fell to normal, but on April 7 temperature 101** 
and rigor. Wound healthy. Temperature persisted till 13tb. NegatiTC reaction* 
He was discharged on May 13, and on June 17 bad first symptom of Mediterranean 
Ferer. 

H. B., Ordinary Seaman. — ^Admitted February 8, 1906, with venereal sore. 
Dereloped temperature, and headache March 16 and 17, but with negatiye reaction. 
Onset April 18 after discharge on March 27. 

J. 8., Str. — Admitted November 24, 1906, with chancroid and bubo. Developed 
a temperature and abdominal pain January 3, 1906, and headache, abdominal pain 
and temperature January 25. Discharged February 1, and onset of Mediterranean 
Ferer on May 12. 

It will be noted that in the list of cases contracted while still resident 
in hospital a very similar history is frequently given — a short pre- 
Uminary canter in the shape of two or three days' temperature and 
malaise, followed in a few weeks by more definite symptoms and 
positive reaction. 

It will be seen from this table that the difference is enormous, more 
particularly when it is taken into consideration that the Fleet number 
represents only the average, whereas the hospital number represents the 
actual total of individuals, and, moreover, that even this is over 
estimated, since several patients are admitted more than once during 
the year. One is, therefore, perfectly safe in asserting that, in the past, 
residence in Bighi for any other illness has enormously increased 
liability to the development of Mediterranean Fever within the next 
duree months. 



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22 Major McCuUoch, Major Weir, and Staff-Surgeon Clayton- 
Table in. — Comparing the Incidence of Mediterranean Fever among 
previous Patienta in Bighi and those in whom no History of 
Connection with that Establishment was to be obtained 



Year 


1902. 


1903. 


1904. 


1905. 


1906. 




Actual number of admiBsions to 
Bighi of patients suffering from 
illness other than M^ter- 
ranean Fever 


1,284 


1,158 


1,346 


1,480 


261» 


Actual number of these who sub- 
sequently, either during resi- 
dence or within three months 
of discharge, are known to 
haye deyeloped Mediterranean 
Fever 


96 


86 


86 


170 


28 


Averaffe number of men yiotualled 
in Mediterranean fleet yearly 


18,470 


18,410 


19,590 


14,360 


— 


Proportion of fever cases dealt 
with vearlv, showing no previous 
hospital history 


190 


155 


144 


150 


80 



* First quarter only of 1906. 

In addition, an examination of Tables lY and V II and Charts 1 to 5 
shows quite conclusively that those cases, classed as almost certainly 
contracted in hospital, display a remarkable correspondence with those 
who merely developed it subsequently to discharge, both with regard 
to the time at which they were resident and presumably contracted the 
disease, the blocks in which they were treated, and the kind of illness 
from which they suffered. 

To summarise : — 

That large numbers of cases have year by year been contracted in 
Bighi is a well-authenticated fact 

A large proportion of cases admitted during each year give a history 
of recent residence there, and it is equally certain that liability to 
attack in the near future is very much greater among patients there 
than among the generality of their messmates. 

In a great many the possibilities of exposure to infection between 
discharge and the onset of sjrmptoms have been practically negligible* 
It is not therefore unreasonable to conclude that the majority of these 
persons have been infected while actually in hospital. 

Description of Bighi Hospital, — In order to throw light on the method 
of infection in these cases, it is necessary to give a short description of 
the hospital and of some points with regard to the routine in force 
there. The grounds comprise an area of about 17 acres on a broad 
bluff of land some 50 feet above sea level, and projecting into Bighi 



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Hpidemiological Work in 1906. 23 

Bay on the southern side of Grand Harbour and between Rinella and 
Calcara Bays. Except, therefore, on the south-eastern side, it is 
entirely cut off from the adjoining land by broad strips of water, and 
is consequently separated from the thickly populated centres — the 
nearest, Vittoriosa, being at the least 260 yards distant. Ricasoli Fort 
to the north-east is 140 yards from the nearest point of the hospital, 
and Valletta is 700. The hospital proper, as opposed to the residential 
area, is on the north- west side, and is therefore furthest removed from 
the small village of Calcara, which adjoins the southern comer of the 
grounds, and is the only inhabited district that does so. The rest of 
the country adjoining is practically uninhabited, and herds of goats 
provide the only possible source of infection. It is obvious, therefore, 
that this is to be sought within the establishment itself. 

The hospital proper originally consisted of two large one-storey 
blocks and of a central block. The former, which contains one large 
and two small wards on each side, separated by a broad central 
corridor, are known as the East and West Blocks respectively, and 
will be so referred to. They also contain cabins for officers at the 
comers and the basements are taken up for kitchens and other offices. 
Above these wards, under the eaves at each end, are two small rooms, 
now unused, but previously to October, 1902, the quarters of the 
Sick Berth staff. Just outside them and at the top of the stairway 
leading to them are large stone tanks, at present kept boarded up, but 
formerly open; these must have provided excellent breeding places 
for mosquitoes. 

The wards have been modernised and are fitted with good sinks and 
latrines. 

An infectious block was added on the western side in 1900, and a 
new general surgical block was first occupied in June, 1903. This 
latter block is three stories high, but, owing to the dip in the ground 
towards the Rinella side, where it is situated, its top storey is beneath 
the level of the old blocks. 

Charts 1 to 4 also show that it is effectually screened from the 
west (the present Mediterranean Fever) block by the interposition of 
the east and central buildings. It consists for the most part of six 
large wards arranged in longitudinal series of twos. The ends and 
comers are filled in with small wards, the various offices, and cabins. 
Both this and the infectious block are built on modern lines and do 
not call for further remark in this direction. 

On the southern or landward side of the grounds are the various 
quarters and residences, and the unoccupied areas are utilised as 
gardens or as asphalted catchment areas for the supply of the under- 
ground tanks. For this reason Bighi is singularly free from dust, 
and, owing to its encirclement by water, receives very little from 
without. 



Digitized by VjOOQ IC 



24 Major McCulloch, Major Weir, and Staff-Surgeon Clayton. 

The arrangements for water supply constitute a noteworthy feature, 
as, owing to the insufficiency of the public supply or aqueduct for fire 
purposes, it is necessary to store water in a series of tanks. 

Drinking vxUer is supplied to all parts of the hospital from the 
aqueduct in iron pipes, the various tape being clearly labelled, " Fit for 
Drinking," but for the water for fire, lavatory, flushing, and garden 
purposes there are several distinct sources. First, there are 36 under- 
ground tanks, many entirely unused, and therefore containing water 
which is stagnant and full of vegetable matter. These are supplied 
by surface water, for which catchment areas are provided by the flat 
roofs of the hospital buildings and the asphalted surfaces of the grounds 
already referred to, while seven of them also have a supplementary 
supply from the aqueduct, the pipes being controlled by stop-cocks. 
No. 14 tank, situated close by the laundry, is used as a reservoir from 
which water is pumped by an engine near here into flushing tanks on 
the roofs of the various residences and of the Eefractory, Zymotic, and 
Central Blocks, and also into the stone tanks already referred to as 
being under the roofs of the East and West Blocks. This water is 
used for lavatory and flushing purposes. In addition, there is a second 
pumping station on the Calcara side, below the Zymotic Block, which 
three times a week fills a third series of seven tanks, three each on the 
roof of the East and West Blocks and one on the Surgical, with sea 
water. This is used solely for the purpose of giving the drainage an 
additional flush, and is turned on once a day for five minutes, while 
at the same time those blocks and residences unprovided with the 
sea-water tanks are flushed by the fresh-water supply mentioned. 

This brief description illustrates the fact that collections of more 
or less stagnant water are exceedingly numerous about the hospital 
grounds and buildings, and to these must be added a large number of 
garden surface tanks and tubs and the innumerable gullies connected 
with surface drainage. It also aflbrds evidence that there is ample 
provision for flushing and that this essential procedure is thoroughly 
and regularly carried out. 

Drainage. — The main drain is contained in a capacious tunnel which 
pierces the solid rock from the Rinella side to join the Grovenunent 
sewer at the southern comer of the grounds. The drainage from the 
Zymotic, East and West Buildings, join at their northern end and 
sweep round on the southern side of the Surgical Block to join the 
main drain at its northern end, so that the drainage from the Mediter- 
ranean Fever wards passes close to this building. 

The drainage system is, however, every way up to date, is well 
supervised, and the arrangements for flushing are probably more 
satisfactory than almost any establishment in the island. ;o irj» .a \a 

Sterilisation of Effects, — The clothing of Mediterranean as well 98 ot 
infectious cases has for some time been sent to the disiiiJe«(»or on 



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Epidemiological Work in 1906. 25 

admission, and where cases occur in the hospital, the regular procedure 
is that bedding and clothing are to be dealt with similarly. 

Stringent regulations have been laid down with regard to disinfec- 
tion of hands by the staff, after dealing with excreta of Mediterranean 
Fever cases. 

The hospital may therefore be described as almost entirely isolated 
from the centres of population, unusually free from dust, built and 
administered on modern lines, and certainly in no way inferior in 
either respect to any hospital in the island, with a water supply above 
suspicion and a system of drainage which is found to work satisfac- 
torily. There are, therefore, three main points which have a bearing 
on the question of the high incidence of Mediterranean Fever among 
residents there : — 

First of all, in the close juxtaposition of sufferers from Mediter- 
ranean Fever with cases of other illness we have a large amount of 
susceptible material in the near neighbourhood of a possible source of 
infection. 

Second. Mosquito breeding places are unusually numerous. 

Third. The hospital has for years been supplied with goats' milk 
c(mtaining Micrococcus meliiensis, and from the work of Staff-Surgeon 
Whiteside, referred to later, it is definitely known that this was, at least 
occasionally, drunk unsterilised. 

The probable methods of infection resolve themselves, therefore, into 
direct or indirect contact, contamination of food-stuffs by various flies 
or their droppings, inoculation by biting flies, and ingestion of naturally 
infected milk. 

DisiribtUum of Mediterranean Fever Cases in Bighi Hospital^ and Effect 
of Propinquity on other Po/ien/».— With reference to the procedure 
adopted in isolating Mediterranean Fever, fortunately, during the 
period 1902 to 1906, different buildings have at various times been 
appropriated for the accommodation of these cases. A unique oppor- 
tunity is thereby afforded for studying the influence of propinquity 
to the potential sources of infection in the production of the disease 
among other patients. It must be premised that before the introduc- 
tion of an observation ward in June, 1905, the Mediterranean Fever 
block did not include absolutely all cases of the disease in hospital, as, in 
addition to undiagnosed cases under observation in the general medical 
wards, an occasional officer or man developing the disease elsewhere 
does not appear to have been transferred. For all practical purposes, 
however, the enormous bulk of infective material was to be found in 
these special wards, and it is justifiable to assume therefore that here, 
too, would be found the principal danger of contraction of the disease 
Vy oontP"' •>r biting flies. Table IV, illustrated in the Charts 1 to 4, 
gives a history of the blocks, the approximate number of persons 
exposed i^ "hem, and the proportion who subsequently developed the 



Digitized by VjOOQ IC 



26 Major McCuUoch, Major Weir, and Staff-Surgeon Clayton. 

disease. It will be seen that the five years must be divided into four 
periods : — 

(1) No isolation. Fever cases in general medical wards W 1 and W 2. 

(2) Almost complete isolation. Fever cases in special ward W 1. 

(3) Almost complete isolation. Fever cases in special wards E 1 
and E 2. 

(4) Complete isolation. Fever cases in special block (West), 
observation cases in special wards (W 3 and W 4) in this block. 

In addition, therefore, to demonstrating the inefficiency of isolation 
by itself, which alone constitutes an argument against any form of 
contact infection, this table and the charts, pp. 27 — 32, show the 
following points : — 

That equally during the first period when the cases were indis- 
criminately mingled with others, and during the second, when 
developed cases were kept together in one ward, the block which 
suffered most severely was the East, as far removed as possible from 
the source of infection, and containing surgical cases. This, which is 
noted alike with the almost certain and with the other cases, may be 
taken as suggesting the improbability of infection by contact or biting 
flies, and the possibility of a place infection (since on each occasion the 
same block was affected), or of something in connection with the 
surgical nature of the cases. That being so, it is interesting to note 
that the third chart puts an end to the idea of place infection, since 
with the removal of the surgical cases to the new block a similar 
condition of affairs is found there also. But since the Mediterranean 
cases were at the same time removed to the East Block, it might be 
argued that this offered some support to the theory of convection by 
biting insects, dust, or other contaminate infection. 

The last chart, however, offers a decided argument against this 
conclusion, since with cases far more satisfactorily isolated at one end 
of the hospital, and with an observation ward provided, the incidence 
still continues to be highest in the Surgical Block, although removed 
as far as possible from the source of infection and screened from it by 
the intervening Central and General Medical (East) Blocks. 

The conclusion that is forced upon one from a study of these charts 
is, that while cases are very generally distributed there is a special 
incidence upon surgical wards, and that residence in them is of greater 
importance in determining the development of the disease than 
propinquity to the Mediterranean Fever cases. 

JRelationship to the Amount of Stisceptible and of Infective Materiai in 
Hospital, — Chart 5 gives these relations in graphic form. It will 
be seen that there is no definite connection between the number 
of persons resident each month who subsequently develop fever and 
the average number of reservoirs of infective material, in the shape of 
cases of the disease who were under treatment during that month. In 



Digitized by VjOOQ IC 



(2089) 



130Z 



Tofacep. 26, 
1906 



200 




CllABT 5 

rnateri 



tlicrthun Mediterranean Fever), and of infectiv*' 
, from January, 1902, to September, 1906. 

case was probablj contracted. 



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Digitized by VjOOQ IC 



Epidemiological Work in 1906. 



27 



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28 Major McCulloch, Major Weir, and StaflF-Surgeon Clayton. 



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Epidemiological Work in 1906. 



29 



R I isr E 



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• Other cAdea. 



C^I^C^TLA. :Bi^Y 



Chabt 1. — Period — January to October, 1902. Conditions — No isolation. Mediter- 
ranean cases on W 1 and 2 with medical oases. Enterics frequently treated in 
Zymotic Block. W 1 and W 2, slightly shaded, show position of large majority 
of Mediterranean Ferer cases. 

Approximate 
number exposed. 

In East Block 62 611 

In West Block 13 429 

In Infectious Block 5 67 



Cases. 



Digitized by VjOOQ IC 



30 Major McCulloch, Major Weir, and Staflf-Surgeon Clayton. 



B. I N E 31. li -A. 



B ^ 




xAbnoAt certaan cMts 
•Other cases. 



CALCAB.A. B AY 



Ghabt 2. — Period — November, 1902, to June, 1903. Condition* — Fairly complete 
isolation. Mediterranean cases in W 1 ward. Observation cases with general 
medical cases in W 2 ward. Mediterranean ward shaded. 



In East Block 

In West Block 

In Infectious Block.. 



Oases. 
41 



Approximate 
number exposed. 
497 
432 



Digitized by VjOOQ IC 



J^pidemiohgical Work in 1906. 



31 



R I isr E li Xi A. 



B ^ 



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B A.Y / 




?^ Almost certain cAees 
•Other cases. 



C-A.LCA.RjfV. BA.Y 



Chabt 8. — Period — June, 1903, to June 22, 1905. Conditions — Fairly complete 
isolation. Mediterranean Ferer cases in £1 and E2. Observation cases in 
medical wards W 1 and W 2. Surgical oases in Surgical Block. Mediterranean 
Ferer wards shaded. 

Approximate 

number Cases, 

exposed. 

24* In Infectious Block 3 
1057 In Central Block 2 

(scabies) 
1571 In Befractory Block 1 



Cases. 

In East Block 10 

In West Block 64 



In Surgical Block ... 188 



Approximate 

number 

exposed. 

32 

93 

24 



* Entries since about January, 1904. 



Digitized by VjOOQ IC 



32 Major McCulloch, Major Weir, and Staff-Surgeon Clayton. 




Chabt 4 — Period— June 22, 1905, to April, 1906. Conditions— Complete isolation. 
Mediterranean Fever cases in W 1, W 2, and W 3. Obserration cases in W4. 
General medical oases in E 1 and £ 2. Enteric cases in E 8. Mediterranean 
wards shaded. 

Cases. Anproiimate 

number exposed. 

In East Block 29 421 

In West Block 6 ? 

In Surgical Block 74 814 

In Infectious Block 1 8? 



Digitized by VjOOQ IC 



Digitized by VjOOQ IC 



Naval Hospital ac^iarge < 
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Jan. 



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— 1 — 

— 1 3 



- ■■■} 1 



1—6 



.- i- 



iJune 2 

Digitized by VjOC^QIC 



Epidemiological Work in 1906. 33 

fact, in the majority of instances, an increase in the number contracted 
in hospital during any particular month appears to precede the months 
during which the largest average number of cases are under treatment, 
and probably is, to some extent, accountable for it. 

As might have been expected, more cases appear to follow a high 
admission rate for diseases other than Mediterranean Fever, or, in 
other words, the amount of the latter disease contracted in hospital 
depends, to some extent, on the quantity of susceptible material 
exposed. The majority of cases are seen to occur in the winter when 
the hospital is most full, but there are occasional rises in the curve 
entirely independent of any recognisable factor. 

Relaiion to Total Number of Cases of all Sorts under Treatment in 
Hospital and to Season, — Table VI, p. 34, compares the ratio of the number 
of Mediterranean Fever to other cases, and the ratio of the number of 
these latter subsequently developing fever to the total number exposed, 
and once more demonstrates an entire absence of any correspondence. 
Incidentally it shows that the rate is higher as a rule with a large total 
number of all cases under treatment, and lower when this is small, and 
that, therefore, the winter rate is usually higher than the summer, but 
that* this rule is belied by occasional outbreaks which do not appear 
to depend upon season or the amount of infective material. Yet 
another argument against mosquito infection is therefore provided by 
Table VI. 

Meteorological Conditions. — The daily temperature, rainfall, and direc- 
tion and force of wind during 1905 and 1906 have been studied in 
relation to the occurrence of cases, but nothing can be discovered 
which appears to have any bearing on the exceptional prevalence at 
certain times, such as May, 1905, and January and February, 1906. 
At the former date the temperature was high and rising, and the 
weather very dry, at the latter the temperature was extremely low, 
and there was heavy rain. There was much wind at both seasons, 
but the force was perhaps greater in the two winter months. The 
wind which would most favour the convection of particles of dust or 
biting flies from the Mediterranean Wards to the Surgical Block would 
be any southerly wind in May, when the East was the Mediterranean 
Block, whereas in January and February, with the West as the 
Mediterranean Block as at present, a south-west wind is practically 
the only one which would produce much effect in this way, and the 
buildings are, in addition, screened from one another. 

In May, north-west, south, and south-east were the prevalent winds, 
and the direction was southerly on 16 days. 

In January, south-west, south-east, and east were the prevalent 
winds, and the direction was south-west on seven days. 

In February the prevailing winds were north-east, south-west, west, 
and north-east, south-westerly on eight days. 

(2089) d 



Digitized by VjOOQ IC 



34 Major McCuUoch, Major Weir, and Staff-Surgeon Clayton. 



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Epidemiological Work in 1906. 35 

To that extent, therefore, the conditions may be said to have been 
favourable for dust or insect convection, but the subject is discussed 
elsewhere in more detail. 

Relationship to Type of Disease for which the Patient vxis originally under 
Treatment, — Table VII gives the ratio of incidence in the various diseases 
for which the patients were under treatment. This once more brings 
out the fact that the distribution is very general, but that certain types 
suffer far more severely than others. Among those for which any large 
number were admitted it will be noticed that catarrh, simple continued 
fever, and influenza show a comparatively low ratio, whereas the 
opposite is the case with enteric fever, the initial stages of venereal 
disease, nervous and ear aff'ections, pneumonia and pleurisy, practically 
all ailments aflecting the digestive tract and the genito-urinary system, 
abscess, and injuries. There is a remarkable immunity in the case of 
tubercular disease, which may be due to the fact that such patients are 
invariably invalided and thus lost sight of, although an antagonism 
between the two is possible, especially in view of the results of experi- 
ments this year. 

If, now, Table VIII, gi\ang the proportion attacked in 1905 and 1906, 
according to duration of residence, is examined, it is first seen that 
a very large majority of attacks of Mediterranean Fever occur among 
patients who have been in hospital for prolonged periods, and, secondly, 
that diseases in which incidence is low are mainly those of short 
duration, while those in which incidence is high provide the greater 
part of the prolonged residence cases. In other words, prolonged 
residence would appear to explain the special liability of venereal and 
other surgical cases to attack, and, at least, may be said to be more 
important than any other condition yet discussed. This is the probable 
explanation of the special incidence in surgical wards. An interesting 
point in these two tables is the comparatively high incidence in sore 
throat and tonsillitis, which would provide a portal of entry for any- 
thing ingested in the mouth, as compared with other diseases of short 
duration. Indeed, there seems to be a specially heavy ratio among 
digestive diseases generally. 

Direct Evidence with regard to Mosquitoes. — From the description of 
the water supply, the exceptional opportunities existing in Bighi for 
breeding of mosquitoes can be readily understood, and their prevalence 
is quite in accordance with anticipation. Surveys in and around the 
hospital were made on several occasions, and the following gives a 
brief summary of the result : — 

The foreshore around Bighi itself is singularly free from larvae- 
containing pools, and numerous examinations showed none. The 
same applies to the northern shore and head of Rinella Bay, and, owing 
to the fact that Calcara Bay has been so largely altered and made use 
of for wharves, landing-places, etc., very few can be found there either. 
(2089) d 2 



Digitized by VjOOQ IC 



36 Major McCulloch, Major Weir, and Staflf-Surgeon Clayton. 



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Epidemiological Work in 1906. 



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38 Major McCulloch, Major Weir, and Staff-Surgeon Clayton. 



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1906 (third quarter). 






Under 10 days. 


10 to 20 days. 


20 to 80 days. 


90 to 40 days. 


Oyer 40 days. 


1. 


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exposed. 


Cases. 


No. 
exposed. 


Gases. 


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Oases. 


No. 
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2 



Digitized by VjOOQ IC 



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Epidemiological Work in 1906. 39 

The nearest point at which larvse were found on the foreshore was 
on the northern side of the Breakwater and around the seaward face 
of Ricasoli, a point at least 500 yards from the nearest portion of the 
hospital grounds. They were found also in large numbers at the 
naval range at Ricasoli, and when bred out proved to be AcarUmyia 
Zammiitii. 

The greater number of the underground tanks are situated in the resi- 
dential area of the grounds, and here, also, the garden tanks, tubs, etc., are 
most numerous. Three of the underground tanks close to the Office Block 
were at one time or another found to be swarming with larvae, which 
on being bred out proved to be either Culex faiigans, pipiens, or spathi- 
palpis. In one or two more, one near the hospital proper, adult 
mosquitoes issued on opening, or cast larvae cases were found, but 
larvae were never numerous enough to be detected. The same three 
varieties of Culex were also bred out from some of the gullies and 
garden tanks, but none were ever found on any of the roof tanks. 

The adult insects were also sent over for some months for identifica- 
tion. Of 156 examined, 75 proved to be C. pipiens, 56 C. fcUigcms, 
22 Stegomyia fasdata^ and 3 Acan-tomyia^ the proportions thus corre- 
sponding very closely to those of Kennedy and Horrocks last year, and 
the small number of Acartomyia bearing out the observations made with 
regard to their breeding places. The first two were most prevalent in 
the early part of the year, Stegomjda in the latter part of August and 
September. 

Since November 13, 1905, systematic oiling of all water traps and 
exposed tanks has been carried out in Bighi every Friday with, it is 
said, good results, although mosquitoes are still very numerous. In 
addition, all flushing tanks and exposed water tanks have been fitted 
with covers. 

To exterminate them, however, in a place with such innumerable and 
inaccessible breeding places is a matter requiring a large staff in itself 
and constant supervision, and the hospital gardener and his assistants 
can hardly be expected to accomplish it. 

Large square mosquito nets were fitted in the Mediterranean Fever 
wards at the end of June, 1905, and small ones in A and B Wards, and 
since October, 13, 1905, other wards have been gradually supplied. 

Although these nets cannot be said to constitute a very efficient 
protection unless carefully looked after by the user, a very doubtful 
matter with the bluejacket, they must be regarded when fitted in the 
fever wards as not only protecting the patient to some extent from 
mosquito attack, but as preventing a certain proportion of infected 
mosquitoes, when full of blood and therefore sluggish, from escaping 
to be a possible danger to others. Accordingly one would expect some 
diminution as the result of their use, and the absence of such constitutes 
one more bit of evidence against this method of dissemination. 



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40 Major McCulloch, Major Weir, and Stafif-Surgeon Clayton. 

Direct Evidence with regard to Milk Infection, The Milk Supply at 
Bighi. — Goat's milk h;is always been the source of supply, and there 
has for a long time been a standing order that it should be boiled 
before issue to the patients, an order that was repeated in July, 1905. 
The goats were brought daily to the main gate of the hospital, Ijeing 
milked in summer just outside in a rather windy and dusty square, and 
in the winter inside a neighl)ouring dairy shed. The milk was collected 
in 10- and 24-pint cans, the former, according to the goatherd, holding 
on the average the milk of four animals and the latter of eight to ten. 
In these it was conveyed three times daily, at 5.30 and 9.15 a.m., and 
1 p.m., to the hospital kitchen for the patients and to the various 
quarters for the staff, sterilisation being presumably effected in each 
separate place. 

In the kitchen the apparatus in use consisted of three copper pans, in 
which the milk was heated until about 98" C, this taking about 
50 minutes on each occasion, and necessitating continued stirring. 

To facilitate rapid heating, instead of emptying a can bodily into one 
copper pan, a little was added to each of the three. It was subsequently 
conveyed to the wards in other special receptacles. 

This method was so obviously imperfect that an Aymard steriliser 
had some time ago been applied for and approved, but up to the end of 
March it had not been fitted. 

From the above facts it is evident that the milk must have luider- 
gone considerable dilution before issue. It is evident, too, that with 
Maltese cooks, possessed of profound faith in the virtues of goats' milk, 
we cannot feel certain that effective sterilisation had been carried out 
when the total number of cases in hospital was great and the work of 
boiling correspondingly heavy. 

Evidence that the Milk was Infective. — Shaw first examined the 
goats supplying the hospital in July, 1905, and found that out of 
91 goats 30 presented an agglutination reaction, and the milk of 
9 yielded the Micrococcus melitensis. The organism was proved to be 
infective for monkeys. In March, 1906, the goats were again 
examined by Whiteside, and, out of 78, an agglutination reaction was 
presented by 21, and 5 of these presented Micrococcus. On July 3, 
1906, the herd was once more examined by Zammit, and, out of 46, 
7 were found to react. For reasons given subsequently, the examina- 
tion was not persisted in. 

p]vidence of Ineffective Sterilisation. — As will be seen on p. 71, 
Whiteside has established, beyond the possibility of doubt, that 
occasionally, at least previously to April 8, 1906, sterilisation was not 
properly carried out in the kitchen. It follows that milk cannot be 
eliminated as a possible vehicle of infection in any case before that date. 

The ingestion by a patient in any particular part of the hospital of 
a dose of infective milk would, to a large extent, therefore depend 



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Epidemioloyiccd Work in 1906. 



41 



upon a combination of factors. The presence of goats in the herd 
who were excreting Micrococcus TnelUensis may be assumed, from the 
examinations, to be practically constant. 

From the method of collection it is evident that, as a rule, the milk 
must have been greatly diluted, but that at any time chance may have 
decreed that one can or one sterilising pan should have contained the 
milk of a large proportion of infected goats, and thus produced a much 
more highly infective dose than usual. 

A third factor would be the varying efficiency of sterilisation. 

In addition to these we have to consider the individual susceptibility 
of the persons drinking it. Whatever may be the reason, whether it 
depends on the presence of mouth lesions or not, there can be no 
question that individual susceptibility to this method of infection, 
if accepted as a method, must vary, since at the time of Whiteside's 
observation numerous men, who have not since suffered, drank the 
milk which was proved to have been infective. 

Duration of residence, therefore, by favouring the combination of 
these factors, and the presence of a large number of patients in 
hospital, by increasing the chances of ineffective sterilisation, may be 
regarded as circumstances which would favour the possibility of milk 
infection. 

Evidence of Milk Drinking. — Of the 471 cases under consideration 
no notes are available in the case of 14, but in at least eight of these 
the disease from which they were suffering afforded a practical 
guarantee that they would be on milk diet, and in the rest it is 
probable. Of the remaining 457 no milk is noted on the case sheets 
of six, while the remainder all had it in varying quantities. One of 
these six cases was almost certainly contracted in hospital and 
developed the disease while resident there. One, however (the only 
patient among the 471 resident for so short a time), was only in 
hospital three days, and the chances are against his having contracted 
it there. The disease from which they suffered was: Syphilis 
primary in three cases, gonorrhoea in one, fracture in one, and new 
growth in one : — 

Table IX. — Showing the Total Amount of Milk Ingested. 



trpu}:^-'"^- «*<"«■ 


11 to 20. 


21 to 30. 


41 to 60. 


Over 60. 


1 1 


50 


lOG 


81 


175 



The vast majority are seen to have had a considerable amount, and 
there is almost a progressive rise in the numbers to the larger 



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42 Major McCuUoch, Major Weir, and Stafif-Surgeon Clayton. 

quantities. This is brought out distinctly in the next table giving the 
number of days on milk, an even more important point to investi- 
gate, taking into consideration the probable intermittency both of 
sterilisation and the supply of infected milk : — 





Table X.- 


-Showing 


the Number of Days 


on Milk. 




Days ... 


1. 


2 to 5. 


6 to 10. 11 to 20. 

1 


21 to 80. 


Otcp 30. 


No. of 1 
patients j 


19 


81 


56 88 


81 


177 



Table XI. — Giving the Interval between the last Issue of Milk and the 
Onset of Symptoms of Mediterranean Fever. 



Intenralll 
in weeks] 1 



None. 



No. of 1 1 y 
patients /{ 



Under Under 


1. 


2. 


16 
f 


25 



Under Under 
8. , 4. 



20 



42 



Under Under 
5. 6. 

1 


Under 
7. 


1 

Under Over 

8. 8. 


46 


88 


46 


1 

1 

26 123 



Naturally the cases which had been discharged for some time 
provide the majority of long intervals, and, equally naturally, those 
contracted while resident give practically all instances of no interval. 

It is interesting, therefore, to give the intervals exceeding three 
weeks in those with onset while resident, within eight days of 
discharge, and from nine days to a month of discharge respectively : — 

Table XII. — Showing the Intervals exceeding Three Weeks in Gases 
giving the greatest Probability of Infection in Hospital. 



Interval in weeks.. 

While resident 

Within 8 days 

From 9 days to 1 month \ 



Under 


Under 


Under 


Under 


Under 


Over 


4. 


6. 


6. 
2 


7. 


8. 


8. 

1 


4 


3 




1 


— 


2 


2 


1 


— 


1 


39 


22 


7 


9 


4 


7 



This shows clearly that if milk is to be accepted as the vehicle of 
infection in these cases — and it is difficult to avoid this conclusion when 
the results of effective sterilisation, as detailed on p. 74, are taken 
into consideration — the prevailing ideas with regard to the duration of 
the incubation period, considered as the interval between ingestion of 



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Epidemiological Woi^k in 1906. 



43 



the infective milk and the onset of definite symptoms, will have to be 
considerably modified. 

There would be nothing in the experimental work yet done to 
negative this view, as the interval is consistently shown to be 
lengthened in this mode of infection as compared with inoculation. 

An interesting point is brought out in this investigation with 
regard to patients suffering from Scabies, who are not usually given 
milk. The circumstances were examined into in eight of these, 
although only six were included in Table I, as one was only 17 days in 
hospital l)efore developing symptoms and another had been discharged 
for more than three months. All, however, without exception, had 
had milk, four only for a short time, but the remainder for a consider- 
able time. It would, therefore, appear that the Scabies cases which 
eventually develop Mediterranean Fever are picked out from the 
very small proportion who are given milk. 

Control. — Staff-Surgeon Eichards kindly provided a list of the 
patients in his wards in the early part of 1906, with the particulars 
shown in Table XIII:— 

Table XIII. — Giving the Milk History of a Series of Cases in the 
Venereal Wards. 



Cases not developing Mediterranean Fever 
Cases developiDg Mediterranean Fever 


No 
mUk. 


Very 
little 
mUk. 


Fair 
amount. 

50 
16 


Large 
amount. 


20 


23 

1 


84 
14 



* This man, a S.B. attendant in hospital, admitted having drunk half a pint of 
unsterilifled milk in his own quarters daily. 

Although this evidence is on the whole in favour of milk, it shows 
once more that the individual must be taken into account, as some men 
from the dates given must have been taking the same milk and for as 
long a time as those who developed the disease. This, however, is in 
accordance with experimental evidence. 

In the next table is shown for each ward during the year 1905 
taken as a whole : — 

(1) The total amount of milk consumed. 

(2) The average consumption per head. 

(3) The ratio of patients in the different blocks who subsequently 
developed fever to the total number of diets issued. By working out 
this ratio the duration of residence which has been shown to be of 
such importance is eliminated as a factor, inasmuch as the cases are 
regarded collectively rather than individually. 



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44 Major McCuUoch, Major Weir, and Staff-Surgeon Clayton. 

Table XIV. 









-| 


t 


CM 

o 


i 1 


5& 








cu 


^ 


U ' 


S Ss 


T 


Description of 
use. 


s 


d 
1 

4 




13 .2 


•is 1 gl 

S§ .2-5 


1 
1 




1' 


1 


> ^ 

< 


r 
















percent 


w n > 
w 2 r 


General medical 


ri44 

120 


7708 


2 


3741 


14 


0-61 


to June 


3180 


21 


1468 


18 


E 1\ 


General medical 


f 49 
132 


783 


1-8 


417 


3 




E 2/ 


after August 


6674 


2-4 


2800 


12 


lo-44 


K 4 
A 
B 
C 


Enteric 


336 
295 
847 
365 


5017 
5733 
8597 
6520 


2-9 
10 
11 
1 -4 


1732 
5302 
7406 
4632 


7 
14 
16 
13 


^0-30 


Venereal 




Operation 


D 


Septic cases 


354 


7791 


1-5 


6204 


22 


E \ 


General medical. 


ri7o 

1237 


3103 


1-6 


1913 


!l 




June 20— Aug. 21 


5022 


1*4 


3424 


12 






Zymotic 


261 


715 


2 1 


261 


2 


0-76 




Officers, surgical ... 


258 


1768 


2-4 


729 


4 


0-54 



Quite a decided correspondence is here shown between this ratio and 
the average consumption per head, and the fact that the ratio in the 
medical wards, when taken in this way, is higher than that in the 
surgical constitutes a further bit of evidence in favour of the \iew 
that it is duration of residence which is the chief factor in production 
of the high incidence in the latter. 

(b) Mediterranean Fever occurring among th^ Sick Berth St^ff. 

The heavy incidence among hospital attendants in Malta has long 
been a matter of common observation, and no investigation of the 
prevalence of the disease in hospital would be complete without taking 
into account this particular section of men. As great a number 
of cases as possible have been enquired into, but only since 1901, as in 
previous years the agglutination reaction was not established as 
a routine method of diagnosis. 

Proportion Affected*— From January 1, 1902, to June 16, 1906, 
including 20 men who were already serving on the former date, 
171 separate individuals have been borne on the staff at Bighi, and of 
those 80 are known to have contracted the disease, while three more 
of the 20 already serving had had it in previous years. About 
47*6 per cent, therefore have at some period or other during their 
residence fallen victims to it. 

• About half a dozen men who were under two months on the staff and were 
not attacked have not been included. 



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Epidemiolofjical Work in 1906. 



45 



Average Durafion of lle^ndence Previous to Contraction, — The shortest 
period recorded is one of 25 days, and in this case the patient had 
contracted gonorrhoea in Malta, and was under treatment for that 
affection when his symptoms appeared. See p. 69, Case 5. 

In five the onset was under two months, and in seven under three, 
a total of 13 within that time; 17 occurred between the third and 
sixth month, and two between six months and a year; 22 more 
contracted it during their second year, and six during their third. 

Taking into consideration the manner in which new arrivals are 
victimised by mosquitoes, this comparatively lengthy period is not 
altogether compatible with the theory of dissemination by biting flies, 
and it has been thought worth while to see if the men joining in the 
hot weather are attacked earlier than those joining in the winter. Of 
38 attacked, therefore, who arrived between April and September, the 
duration of residence in seven was under three months, and in eight 
between three and six, while of 41 joining during the winter period 
the figures were seven and nine respectively. The case with only 
25 days joined in Msrch. 



Table XV. — Showing the Proportion in which various Ratings are 

affected. 



Total exposed ... 
Contracted fever 
Percentage 



3.B. stds. 


S.B. Btds. 


2nd S.B. Btds. 


S.B. attendants. 


7 


12 


24 


127 


4 


5 


8 


61 


67 


42 


33 


48 



Three of the attendants are known to have been protected by 
previous attack. 

These figures show quite as great a liability among those not 
in actual attendance on the sick as among the nursing section. 

Rel<Uio7iship of Attacks to Duties. — Table XVI shows the (hity upon 
which the patient was engaged immediately or closely preceding the 
onset of the attack in the cases occurring during each of the four 
periods into which the time under consideration has previously been 
divided. See p. 46. 



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46 Major McCuUoch, Major Weir, and Staff-Surgeon Clayton. 



Table XVI. — Giving the immediate Duty engaged upon, as compared 
with the Average Number employed, among the 80 S.B. Staff who 
suffered from Mediterranean Fever since January, 1901. One 
ambulatory case omitted. 

Period I. — No isolation. January, 1901 — October, 1902. 



Ward or duty 

employed in 

or upon. 



Employment 
of ward. 



Oases 

: amoDK 

staff. 



Arerage 

number 

employed. 



West I 



Webt II. 



West IV .... 
Surgical Block ... 
Zymotic Block ... 

Night patrol 



r 6 



Medical, 

including J o ^ 
Mediterranean ' ' 

Fever cases i 



L-J 



Not opened yet | 

1 

I 



Mess kitchen 

Oil. SB. stewards 
Total 



20 



Remarks. 



Officers I Medical and 4 i 7 

{ surgical cases | 

Ea<»t I and II ...1 o . , « ' e- a 

East III and IV I } ^^'g^^*^ cases 3 5 4 



I 



Of the? e — 1 was only em- 
ployed 14 days and I was 
only employed 9 days. In 
East Block previously. 
1 was only employed 9 dye. 
and in zymotic previously ; 
I wasonlj employed 7 dys. 
and previously with 
officers ; 2 others were on 
night duty 



Night watch for 19 days. 
W 2 for 7 days previously 

This was succeeded by 
rheumatism for a month. 
Then worked in officers' 
cabins for a month and 
was sick June 5, 1902, 
with neuritis, both sciatics 



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Epidemiological Work in 1906. 



47 



Table XVl-^coniinued. 
Period II. — Almost complete isolation. October, 1902 — June, 1903. 



Ward OP duty 

employed in 

or upon. 



I Officers 



East I and 11 .. 
East III and IV 

West I 

West II... 



I 



West IV 
Surgical Block .. 
Zymotic Block .. 



Mesa kitchen.... 
General duties . 

Total 



Employment 
of wards. 


Cases 

among i 

staff. 


Average 

number 

employed. 


Bemarks. 


Medical and 
surgical cases 


2 


6-6 




• Surgical cases 


3 


7 




Mediterranean 

Ferer 

General 

medical and 

obtervation 

Tubercle 


1 

1- 


4 
8-6 




Not opened yet 








— 


1 


— 


G. D. for 5 days immedi- 
ately preceding sick list. 
Night duty in zymotic 


— 


1 1 






— 


1 




For 11 days. Night watch 
in £ 1 preyiouely 


— 


9 



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48 Major McCulloch, Major Weir, and Staflf-Surgeon Clayton. 



Table XVl—continwd, 
Period III. — Almost complete isolation. June, 1903 — June 22, 1905. 



Ward or duty 

employed in 

or upon. 


Employment 
or wards. 


Cases 

among 

staff. 


Average 

number 

employed. 


Remarks. 


Officers 


Medical and 
surgical oases 


6 


G 


1 of these for 9 days only. 
C^eneral duty previously. 
1 on sick list just pre- 
viously 


Eastland II ... 
East III and IV 


Mediterranean 
Fever wards 
Enteric ward 


4 
2 


. 7-3 




West I f 


General 

medical and 

obeerration 

wards 

Surgical. 

Opened 

June 15, 1903 


1 

1 
7 


12-6 


Zymotic subsequently for 
for 21 days preceding 
relapse 


West II 


Surgical Block ... 


Zymotic Block ... 


— 


1 


— 


Zymotic for 20 days. Pre- 
viously on list with 
dyspepsia 


Laboratory 


— 


2 






Night patrol 


"" 


2 


— 


1 had just been sick with 
epididymitis 


Mess kitchen 


_ 


1 




For 11 days only. The 
surgical side previously 


General duties ... 


— 


2 




1 for 9 days. Night watch 
west wing previously 


Ch. S.B. stewards 


— 


1 






Refractory Block 
Total 


— 


1 




For 12 day only. In 
zymotic previously 


31 



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Epidemiological Work in 1906. 

Table JNl—(mi%nued. 
Period IV. — Complete isolation. 



49 



Ward or dutj 

employed in 

or upon. 



Emplc^nuent 
of wards. 



Oasee 

among 
staff. 



Ayerage 

number 

employed. 



Bemarks. 



Officers 



East I and n ... 

Sast in and IT 

West I 1 

Wertill J 

West IV 

I Sorgieal blook ... 



Medioal and 
snrgioal cases 

General 
medical wards 
Enteric ward 

Mediterranean 
Feyer wards 

Obserration 
ward 

Surgical 



6*4 



{: 



10 



1 surgical side, 2 medical 
side 



1 ni^t duty 



}m: 



night duty E wing for 
3 niehts just before sick 
probably a relapse case 



' Mess kitchen.... 
C^eneral duties . 

i 

Total 



11 1 ni^ht duty £ wing for 

I 6 nights, 1 mess kitchen 
I for 4 days, 1 for 18 days 
I Wl, before whichmedical 



1 case employed in yarious 
wards, but exclusively in 
Surgical Block, and is 
there included 



19 



It is seen that of the total number (79),^ 15 had been working in 
the Mediterranean Fever wards just before going sick, but that one of 
these was almost certainly a relapse, and four others were employed 
here for so short a time that there is considerable reason for doubting 
any connection. 

One notable feature is the large proportion attacked while in 
attendance on officers, not necessarily Mediterranean Fever cases, and 
it is curious also that of those who were attacked while on duty in the 
Mediterranean Fever wards so large a proportion should have occurred 
before isolation was adopted. 

A record of night duty is to be found in 13 out of the 79, and in 
three of these a period of general duty^ lasting five, nine, and 11 days 
respectively, intervened between the spell of night duty and their 
going on the sick list. Only in three cases was the duty in the 
Mediterranean ward, and two of these occurred during the period 
before isolation. The third, K B., was on duty in the East wing from 



(2089) 



* One ambulatory case omitted. 



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50 Major McCulloch, Major Weir, and Staflf-Surgeon Clayton. 

April 26 to May 1» 1905» and was placed on the list on May 14. He 
had previously been for months on day duty in these wards. 

Of the rest, three were on night patrol, two on night duty in the 
Zymotic Block, one in £ 1 when it was a surgical ward, one in the 
General Medical Block in 1904, and three closely following one 
another on duty in the East Block in 1906. In two of these latter, 
however, the period of duty there was only three and six days respec- 
tively, so that the chances of infection being then contracted are 
distinctly dubious. 

Practically half the 13 and all the most suggestive cases occurred 
before isolation was adopted, and the evidence derived from this 
analysis of the employment at the time of onset cannot be said to 
favour the idea of infection by direct contact, as the result of 
attendance on Mediterranean Fever cases, or inoculation by biting 
flies. Onoe again, the chief characteristic is the very genend 
distribution. 

The consideration of the immediate duty upon which the patient 
was engaged to some extent loses its value as evidence from the fact 
that it is so difficult in this disease to determine the date of the first 
manifestations, more particularly when dealing with persons constantly 
exposed to the danger of infection. In the following paragraphs, 
therefore, the presence or absence of infection in those who did or did 
not work in the Mediterranean Fever wards is dealt with without 
discussing the question of dates : — 

Before isolation was started in October, 1902, there had been from 
January 1, 1901, 31 persons working in the wards in which Mediter- 
ranean Fever was treated, of whom 13 developed fever during this 
period, and seven long afterwards. During the same time, of 16 who 
had not been on duty there seven developed the disease and three 
more subsequently. 

After the commencement of isolation in October, 1902, down to 
June, 1906, of those members of the staff who have joined after July, 
1902, 73 at one time or another have served in the special Mediter- 
ranean Fever wards either by day or night, or both, and of these 33 
have subsequently fallen victims, but in one the case was an ambula- 
tory one, and the man never went sick. Two, however, were made 
more or less immune by a previous attack in 1900. During the same 
time, of 59 men who have never worked in these wards 25 have 
developed fever. This latter section naturally includes also a larger 
ratio of recent arrivals, and therefore persons who have been less 
exposed to risk of infection. 

Examining into the question of night duty in the same way, it 
is found that of 17 persons on night duty in the block in which these 
patients were treated before isolation was started, five were attacked 
during the period and six long after, while of 46 on duty in the 



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Epidemiological Work in 1906. 



51 



special fever wards after October, 1902, 15 subsequently suffered from 
fever. 

Those on duty in summer would naturally be more exposed to the 
chance of infection by mosquitoes, yet if we divide the year into two 
periods we find the number attacked to be practically equal in both. 
As many men, however, have been on duty both in winter and summer, 
no accurate table can be constructed. 

Since the introduction of mosquito nets in the fever wards in 1905 
there have been only two cases out of 12 men exposed on night duty, 
which would appear to offer support to the theory of mosquito 
<M>nvection, but a large proportion of these men are recent arrivab, 
and since March, 1906, other factors have to be considered, so that 
a comparison is not exact. A similar objection applies to the day 
duty figures, which give 30 cases among 52 persons on duty before 
June, 1905, and only 10 cases out of 39 persons (including several of 
the preceding 52) for the subsequent 12 months. 

Table XVIL — Showing Duration of Duty in Mediterranean Wards by 
Day and Night from October, 1902, to end of May, 1906, and the 
Proportion Attacked. 



Time m days. 


Number 
exposed. 


Number 

attacked 

subsequently. 


Bemarks. 


Under 20 


7 1 A 


1 other in 1900 
1 „ 1900 

An ambulatory case 


Between 20 and 40 

„ 40 „ 80 

., 80 „ lao 

„ 120 „ 200 

„ 200 „ 300 

Orer 800 


16 
16 
11 
18 
7 
2 


8 
6 
6 

7 
2 

1 


Total 


72 


88 





Table XVIII. — Showing Duration of Night Duty alone. 



Time. 


Number exposed. 


Number attacked 
subsequently. 


Under a fortnight 


10 

I • 

17 

4 
8 
1 


3 
8 
2 

4 
2 
1 


Between 2 and 8 weeks 








6 weeks and 2 months......... 


Orer 2 jmonthsr r ,...,..,,..,,..-,,,,.,,,,.., 


Total 


46 


16 





(2089) 



e 2 

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52 Major McCuUoch, Major Weir, and Staflf-Surgeon Clayton. 



Taking as a whole the evidence with regard to the nature of the 
duty upon which the Sick Berth Staff have been engaged, it must 
be held that very little connection can be discovered with work 
amongst the fever patients, either by day or night, winter or summer^ 
and that, just as with the hospital patients suffering from other illness, 
propinquity to these cases seems to exercise little influence in deter- 
mining an attack. 

Table XIX. — Month of Onset and Proportion affected each Year. 



Month of onset. 



1901. 



1 
1902. : 1908. i 1904. 



1906. 



1906. 



Total. 



January .. 
February .. 

March 

April 

Mlay 

June 

July 

Auguit 

September 

October 

NoTcmber 
December 






3 
6 

11 
6 
8 

11 
8 
7 
8 
7 
7 
2 



Total 5 


19 


12 


17 


12 14 


79 


Number actually 1 1 gi » , ei 
serving \ J j 


66 


76 


80 


76 to May 22 



* Together with six -who joined December 17, 1901. 
include a number of the same men in consecutive years, 
was 171. 



These figures naturallj 
The total number serving* 



Like Chart 5, this table illustrates the fact that attacks of Mediter- 
ranean Fever display no special predilection either for the time of year 
at which mosquitoes are most active and numerous or for the months in 
which the largest numbers of fever cases are in residence. Once again 
the prevailing features are the lack of consistency in the various yeara 
and of relationship to any recognisable conditions. 

It will be seen, for instance, that the system of isolation commenced 
in October, 1902, has had no effect on incidence, and this is even more 
plainly shown since the perfected isolation measures instituted in June^ 
1905. Nor has the shifting of the quarters of the staff from the little 
rooms in the near neighbourhood of the sick, under the eaves of East 
and West Blocks, described on p. 23, where they were located till 
about October, 1902, to a building some distance from the hospital 
proper, had any more effect in diminishing the number attacked. 



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Epidemiological Work in 1906. 53 

Description of Quarters, — ^These consist of the two uppermost floors of 
a building (formerly the infectious hospital) projecting towards Calcara 
Creek from the south-western corner of the hospital grounds and about 
dO yards distant from West Block. Built as it is alongside the cliff 
on which the hospital stands, it is considerably below the level of 
the rest of the establishment and is approached from it by the roof; 
The basement consists of dockyard storehouses. The upper floor is 
mainly taken up by a long dormitory with windows on three sides, one 
large one facing the present fever block. Another small ward on the 
lower floor, facing south, was used as a sleeping place until early in 
the present year. The large dormitory is partly divided lengthwise 
by arches, and at the northern end of the inner half a portion is 
screened off to act as a sleeping place for the night duty men. There 
are two cubicles at the south end of its outer half for the ward- 
masters. (See accompanying Plan, p. 54.) 

The sanitary arrangements conform with modem requirements and 
are in good order. No utensils are ever used in the dormitories for 
urinating, the latrine, which is entirely shut off from it, being invariably 
made use of. Four men are told off weekly for duties connected with 
the mess, two as cooks and two for cleaning and general duties. 

When cases of Mediterranean Fever occur the practice has been to 
send bedding, but not the beds, for disinfection. 

Mosquitoes are said to be very numerous in these quarters, and 
although few were sent for identification, the situation so near a large 
number of tanks, etc., found to contain larvae, lends colour to this 
statement. A certain number of mosquito curtains were supplied for 
the first time in April, 1906, but only to some of the men. 

Condensed milk has been used for a long time in the mornings, but 
till about the middle of April goats' milk, not infrequently unsterilised, 
was used in the afternoons for tea. The practice was then discovered 
and stopped. 

The Outbreak among the Staff in 1906. — A considerable outbreak 
occurred in the early part of this year, commencing at the end of 
January. One case was put on the list in that month, three in 
February, five in March, two in May, and one in the early part of 
June. It had been noticed that mosquitoes were especially trouble- 
some during the winter, and it was found by Staff-Surgeon Whiteside, 
on examining the sleeping billets of these cases, that there was a 
marked grouping at the northern end of the outer side of the large 
ward close to the window facing the Mediterranean Block, the prevail- 
ing wind having been blowing in this direction. This, of course, 
suggested the possibility of aerial infection by dust particles or by 
biting flies. There was, however, another possible source of infection, 
inasmuch as Beds 9 and 10 £ {vide Chart 6) were and had been 
occupied for a long time by two men who, without ever going on the 



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54 Major McCulloch, Major Weir, and StaflF-Surgeon Clayton. 




Showing the s^^upin^ of caoes in the sleeping quarters, 
of the SIcK Berth Staff in 1905-1306. 
1905 caeeft thue i-BennetC, 1906 caeee thua:-Hart. 
Chabt 6. 



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Epidemiological Work in 1906. 55 

list with fever, had been very seedy some year or more previously, and 
both of whom possessed high agglutinating power, in one case up to 
1 in 300. One of these two subsequently went sick (Payne), and a 
second case occurred in a man sleeping in the same bed. The possibility 
of these men or one of them serving as the focus of infection, either by 
infected urine or by acting as the reservoir by which biting flies became 
infected, could not be ignored. 

With the idea of eliminating one of these possibilities, the urine of 
both cases was plated out, but without recovering the specific micro- 
coccus. 

In order to collect evidence for or against the possibility of convey- 
ance of infection from the Mediterranean wards either by dust or 
mosquitoes, Staff-Surgeon Whiteside kindly obtained, as far as possible, 
the sleeping billets of the cases in the previous year. As will be seen 
in Chart 6, these show an entirely different grouping and do not at all 
suggest this mode of infection. 

JUlaiionship to jprevious Attacks of Illness, — In 18 cases out of the 
total number, 78, the patients had previously been on the sick list 
within a month or two with what was diagnosed as some other ailment. 
In nine of these the disease was returned as catarrh, influenza, rheu* 
matism, or simple continued fever, a fact which rather suggests that 
these were really the first manifestations of Mediterranean Fever. 
The following case affords evidence in favour of this. A.S. joined 
hospital in January, 1906, and at once went on the list with 
gonorrhoea from January 18 to February 9 ; he went sick again on 
April 5 with what was called influenza. On the 5th his blood gave 
a minus reaction ; on the 7th, a doubtful 1 in 10. On the 18th he 
returned to duty apparently well, and on the 26th was vaccinated 
with dead Micrococcus meliiensis, his blood being examined at the same 
time and found to react 1 in 50. On May 24 he again went on the 
list with developed Mediterranean Fever and reacted on May 26 
1 in 100. 

The remaining 8 cases were — gonorrhoea 2, chancroid 1, laryngitis 1, 
abscess 2, epididymitis 1, and anthrax 1. 

It is an interesting consideration in the first place as to whether 
these cases were in any way connected with the subsequent attack, and 
if so, in what manner. There is considerable reason to suspect that of 
the first nine, some cases, at least, were the first manifestations, and 
this justifies to some extent the remarks made with regard to the 
unreliability of figures where the time element is taken into account. 

In a large proportion, however, the fact of being on the list would 
mean the ingestion of milk, and, on the other hand, a certain amount 
of debility would be produced and lessen resistance. 

Fa>eis elicited by the Study of Individual Cases in Hospital Staff, — Eight 
of the Sick Berth Staff and one man belonging to the hospital guard 
were personally examined. 



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56 Major McCulloch, Major Weir, and StaflF-Surgeon Clayton. 

All of these men lived in adjacent quarters, the house where the guard 
were accommodated being just on the side of Bighi steps, opposite to 
the quarters of the staff which have already been described. The 
majority of these nine men went ashore occasionally, but five stated 
that they never slept out of their quarters. 

Milk History.— Oi the Sick Berth Steff, five admitted drinking milk 
by itself, a sixth had occasionally taken it with strawberries, but the 
remaining two denied having taken it except in tea. In forms sent in 
to my predecessor, information had been provided about eight other 
cases among the Sick Berth Staff. Of these, five admitted drinking 
milk, but one of them only in tea, while no details on this point were 
provided with regard to the remaining three. With regard to the man 
belonging to the hospital guard, which numbered 13, he had been in 
the habit of taking about a pint of milk daily, but said that he 
always heated it until a scum formed. According to his comrades, 
however, there was considerable reason to doubt the accuracy of this 
statement. Only 1 of his 12 messmates was in the habit of taldngmore 
than a very small quantity of milk, and that always in tea. 

Mosquitoes, — Seven of the men had mosquito nets, but at least two 
had only lately obtained them. Five stated that they were badly bitten 
on arrival some time previously, but not latterly, two that they were 
occasionally bitten, and one not at all. The man belonging to the 
hospital guard said that there were numbers of mosquitoes about, but 
that they did not trouble him, although last year he suffered severely. 
He had a small net, but it only covered his face and hands, and was 
probably of little use as a protection. 

Cmtact with previous Cases. — One man had, until six days before onset, 
been working for months in the Mediterranean Fever wards and six 
more had occasionally had cases of the disease to nurse, but not mor^ 
than one or two, or for longer than a few days. In one case there was 
no history of contact with Mediterranean Fever cases. 

Hand Disinfection, — One man, who had been nursing one or two cases 
in the officers' medical wards, admitted that he did not always disinfect 
his hands after dealing with possibly infective excreta, and two others 
were said to be casual and not unlikely to neglect the regulations with 
regard to this precaution. The others, however, all insisted that they 
were most careful about it. 

No other case had occurred for months in the hospital guard, and 
the remaining men when examined all gave negative reactions. The 
only manner in which the patient was likely to have been exposed was 
as sentry in front of the fever block. 

(c) Mediterranean Fever occurring in the other Residences <md Quarters, 

There are notes since January, 1902, of attacks in two nursing 
sisters, three surgeons, one chaplain, and four of the hospital guard. 



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Epidemiological Work in 1906. 57 

Two out of the three surgeons were constantly engaged in laboratory 
work, and in both the infection was considered to have been acquired 
while 80 occupied. According to this, therefore, oflScers would not 
appear to suflfer in any greater ratio than their fellows outside hospital. 
Although they must be regarded as far more exposed to the risk 
of contact infection or the attack of infected mosquitoes, there is no 
reason to imagine that they are more in the habit of taking milk than 
those latter. 

(d) Mediterranean Fever occurring in the Hospital Ship " Mains" 

As so many of the patients who develop their first attack in 
England or on passage home are conveyed in the " Maine," it seems 
well to indicate here the reasons for thinking that such persons have 
contracted the infection in Bighi before leaving Malta. 

Although this ship is, on the whole, well fitted for the purpose for 
which she is used, no ship can possibly compare with a shore establish- 
ment as a hospital for cases in which infection may be spread by 
contact, and if this were a frequent method of propagation, the 
" Maine " ought to be a well-recognised centre. 

She has been running since 1901, and has alternately been used as 
a hospital on the station and for the conveyance of invalids to home 
ports. 

The Sick Berth staff, up to July, 1905, numbered 12 and a ward- 
master, but since then have been increased to 18. As a rule they are 
drawn from home hospitals, and, as the majority are yoiuig attendants, 
a previous history of Mediterranean Fever is uncommon among them. 
Most of them sleep in their own quarters forward, but some in the 
convalescent ward in close relation at times to Mediterranean Fever 
patients. 

Until March, 1906, it was customary for three to be on night duty 
in watches, one for each ward. Mosquitoes are said to be frequently 
troublesome in their quarters, but not much in the wards. The 
remainder of the crew number 96. 

Accommodation and Routine. — There are two main wards, holding 
about 50 patients each, the cubic capacity per bed varying from 480 
to 600 cubic feet. Ventilation, which is partially effected by exhaust 
fans, is said to be very satisfactory, but the latrines are situated before 
and open directly out of the wards, and if a door in the forward bulk- 
head of the latrine is open the air is driven into the ward. 

There is no attempt at isolation of Mediterranean Fever^ cases being 
indiscriminately mingled and no mosquito curtains used. 

Everything is disinfected in cases of typhoid and tubercle, but on 
account of the numbers carried, the beds themselves are not always so 
treated in cases of Mediterranean Fever. Similarly, the stringent 
instructions with regard to hand disinfection by the staff in case of 



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58 Major McCulloch, Major Weir, and StaflF-Surgeon Clayton. 

typhoid are not made a point of in Mediterranean Fever, and no 
disinfectants are used for bedpans. 

Milk Supply, — In January, 1904, an order was given that fresh milk 
was to be used when procurable, but it was not made use of to any 
extent and was rescinded in August of the same year, since which time 
no fresh milk of any sort has been used in the ship. 

EmploymerUs, — From December, 1903, to May, 1905, she acted as a 
hospital for destroyers, and lay most of her time in Lazzarretto Creek* 
Previously to that her work varied between trips to England and 
employment on the station, and since that date she has exclusively 
been used for the former purpose. Up to December, 1905, she had 
made 12 trips home, and had conveyed in that time a total of 
483 Mediterranean Fever cases and 736 other patients, these being on 
board an average of 10 days apiece. While on the station she has had 
under treatment 181 fever cases, with a total days' sickness of 3630, 
and in the corresponding period 881 cases of other illness, also for long 
periods. From these figures, it is evident that there was an abundance 
of infective material on board, even when lying in Lazzarretto Creek, in 
the near neighbourhood of innumerable breeding places for Acartomyia, 
and also that a large number of non-immune and debilitated individuals 
have been in close contact. 

Whether or not cases which have developed at home after passage 
have actually been contracted on board, it is impossible to say 
definitely, but the following facts argue against it. 

In a large proportion of the cases developing after leaving Malta in 
the *' Maine,'' the onset is said to have occurred during the 10 days on 
passage in the ship. 

Again, with the exception of two cases which occurred in August 
and September, 1902 (before fresh milk was prohibited), no records 
can be foimd of any definite case among her staff or crew. Nor was 
any patient whose case sheet was examined among the many admitted 
to Bighi from destroyers during the period in which the " Maine " was 
acting as hospital for them suspected to have contracted his disease on 
board. 

This is a very different record from that at Bighi, and affords- 
justification for considering the balance of probability to be in favour 
of their contraction there. In view of the large number of cases 
gathered together under disadvantageous circumstances as regards 
space, ventilation, and isolation, and with no special precautions^ 
it also constitutes a decided argument against any form of contact 
infection. 



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Epidemiological Work in 1906. 59^ 

(e) Summary of the Evidence obtained in Connection with the Contraction of 
Mediterranean Fever in the Boyal Naval Hospital^ Bighi, 

The foregoing investigatioii may be held to have fairly conclusively 
proved the following points : — 

(1) That a very considerable proportion of cases contracted the: 
disease in Bighi. 

(2) That the distribution of cases is very general, both as regards; 
localisation in wards and the particular form of illness which acts 
as the forerunner, but that there is a special liability among surgical 
cases. 

(3) That apparently this is to be explained by the fact that surgical 
cases provide the greater number of those patients who are resident for 
a long time. 

(4) That there is no indication of place infection, nor does- 
propinquity to the potential sources of infection appear to have nearly 
as great an influence in determining the subsequent development of 
the disease as duration of residence, while no definite relation can be^ 
shown either to the amount of infective material in hospital or to the 
particular season of year. 

(5) In short, that little evidence can be obtained in favour of direct, 
inoculation while in attendance on the sick, inoculation by biting flies» 
direct contact, or dust infection. 

(6) The proportion affected, however, seems to vary to some extent 
with the amount of susceptible material in hospital in the shape 
of cases of other illness and with the absolute total of patients. 

(7) There are occasional outbursts of epidemicity, however, which 
show no relation to any special condition, but under the circumstances 
(with an infected milk supply) it is difficult to banish the idea of the 
existence of a more than usually gross infection or of an equivalent, 
absence of sterilisation. Even apart from the possible necessity of 
repeated dosage, the conditions of supply are such that long residence 
would favour the possibility of ingestion of infective milk. Finally^ 
the direct evidence obtained about milk and, above all, the total 
cessation of cases since there has been no doubt about its sterilisation,, 
are strongly in favour of its having been the infective agent. 



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60 Major McCuUoch, Major Weir, and Staflf-Surgeon Clayton. 



IL — Analysis of Cases showing no very definite Connection 
WITH Residence in Bighi. 

^ Table XXI. 



Year 


1902. ■ 1903. 


1904. 


1905. 


1906. 


Total. 


Doubtful hospital cases 

Cases in hospital more than 
8 months preTiouslr 


2 
5 


6 
6 


7 

1 


3 
4 


4 


18 
20 


Officers^ ward room 


39 

48 

6 


20 
16 

1 


16 
15 


18 
9 

1 


7 

7 
2 


100 

90 

9 


„ gunroom 

ty warrant 




Total 


87 


87 


81 


28 


16 


199 


Maltese senrice men 


7 


(5 


6 
1 

8 

2 

89 


8 

11 

2 

98 


8 
5 
2 

2 

47 


35 
14 
39 

11 

1 
400 


Dockyard employees (English) ... 

Men belonging to dep6t ships in 
Malta 

Cases giying no reaction or other- 
wise indefinite 

Foreigners 

No particular oharactoristics 


4 
7 

81 


4 

11 

5 

1 
85 



III.— Occurrence of Mediterranean Fever among Officers 

AS COMPARED WITH MeN. 

Of the 471 patients who had previously been under treatment in 
Bighi for other illness, 21 were officers, 14 being ward room, 5 gun 
room and 2 warrant, while the list of cases having no obvious 
<!onnection with treatment there {vide p. 60) includes 199 officers of 
various grades or 220 in all as compared with 1056 men. Officers 
therefore suffer at the rate of one to every six men. The relative 
proportion of officers to men in the Fleet, of course, varies slightly,* 
but may be put down at 1 to 16 and the incidence is accordingly very 
much greater among the former than the latter. But the most 
curious feature is the difference between them as regards previous 
hospital residence. Thus, of 220 officers only 21, or if cases among 
the staff are included, 25, give such a history, whereas of 1056 men, 
450 together with 74 of the staff and 4 of the hospital guard, or 
^a total of 528, enter into this category. In other words, it appears to 
be necessary for the man to go to hospital to contract his fever in 
about 50 per cent, of the cases, while the officer is enabled to do so 
without this in all but about 1 1 per cent. The explanation that at 
once offers itself is, that the officer is allowed to have milk in the ship 

• Early in 1906 there were 846 officers in a total of 13,628. 



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Epidemiological Work in 1906. 



61 



and that the men are not, except when on the sick list, and that the 
officer is far more liable to take milk in various forms when ashore 
than is the man. Judging from personal experience, it would seem 
rather a difficult matter, unless one is constantly on the &lert, to avoid 
taking in clubs and hotels in Malta raw milk in such various insidioua 
forms as creams, meringues, sauces, ices, etc. 

It might, however, be suggested that the officer is more exposed on 
account of his shore-going propensities, and in this there is a certain 
degree of truth. With the exception of the comparatively small 
number of officers who live ashore, however, the bluejacket is far 
more in the habit of sleeping there, more particularly as compared 
with junior officers, who contribute so many of the cases, and not only 
so, but he is likely to sleep in places more densely populated, more 
infested by mosquitoes, and where beds are not protected by nets as 
they are in most clubs or hotels. This is illustrated in the personal 
investigation of the movements of patients attacked by Mediterranean 
Fever as detailed on p. 100. 

It may also be regarded as somewhat remarkable that the officer 
should be comparatively immune after residence in hospital and that 
this rather suggested the influence of the greater isolation which 
cabins provide there. Not only, however, has the small part played 
by propinquity to the fever wards been sufficiently demonstrated, but 
a good many officers must have been accommodated in rooms 
considerably nearer to the fever block than the men in the surgical 
wards for instance. It is distinctly curious, however, that in view of 
the large amount of milk allowed to officers they should so rarely be 
attacked after stay in hospital. I 



Table XXII. — Comparing the Ratio of Officers and Men respectively 
after Stay in Hospital. 



Year 


1902. 


1903. 


1904. 


1906. 


1906. 


Total. 




Number of officers 
exposed 


92 


100 


108 


75 


17 


392 


Number attacked... 


4 


4 


4 


7 


1 


20, or 
5*1 per cent. 


Number of men 
exposed 


1192 


1068 


1288 


1406 


244 


5138 


Number attacked. . . 


92 


81 


82 


163 


27 


445, or 
8*6 per cent. 



It is seen, therefore, that there is a very decided difference, but it is 
probably explained to a large extent by the next table, which 



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62 Major McCuUoch, Major Weir, and Staflf-Surgeon Clayton. 

contrasts the duration of residence in the two cases. A point worthy 
t>f note is that the percentage of officers admitted for Mediterranean 
Fever to the total admissions of that disease is much higher than the 
percentage admitted for other illness, which affords fiu'ther proof of 
their special liability to the former. 

"Table XXIII. — Contrasting the Duration of Besidence in Hospital 
among Officers and Men admitted to Bighi for Illness other than 
Mediterranean Fever. 



Day { 


Under 
10. 


10 to 20. 


20 to 30. 

76 

4 

884 
88 


30 to 40. 


Over 
40. 


Duration of rendenceof oflioen 
from January, 1902, to end 
of fimfc auarter. 1906 


80 

296 
20 


126 

8 

470 
29 


46 

4 

240 
81 


68 
2 

420 

85 


No. deyeloping Mediterranean 
Feyer 


Duration of residence of men 
for 1906 and fint quarter of 
1906 (from Table VIII) 

No. developing Mediterranean 
Ferer 





The difference shown here is only what might be expected, as 
with officers Mediterranean Fever itself is the principal disease 
necessitating a long stay in hospital. From venereal disease, which 
constitutes the bulk of such cases among the men, officers are 
<5omparatively free, and they are rarely admitted for hernia or similar 
operations. ^ The number exposed, too, during months such as 
May, 1905, in which there was a special danger of contracting the 
disease and in which a very large proportion of the total apparently 
became infected, is altogether insignificant as contrasted with the 
number of men in residence at the same time, and this also would 
tend to a larger ratio among the latter. 

The yearly returns are also interesting. In 1902 there were 91 
officers attacked, in 1903 41, in 1904 35, in 1905 35, and in 1906 17. 
The first year, which provided by far the greatest number, was 
peculiar in that fewer men suffered than usual, and the Army figures 
were also unusually low. These facts are far more compatible with 
some strictly limited source of infection such as milk supply than 
with conditions such as dust or mosquitoes, which would act more 
generally. 



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Epidemiological Work in 1906. 63 

IV. — The Connection of Outbreaks of Mediterranean Fever 
WITH Stay in Dry Dock or alongside Dockyard Wall. 

For a long time such a connection has been a matter of common 
observation and has been frequently cited as a strong argument in 
favour of the mosquito-borne origin of the disease. This was 
therefore one of the questions which demanded enquiry. Eetums 
were obtained and forms made out giving as far as possible the 
history of ships docking or alongside the dockyard wall since January, 
1904, the cases occurring during this time, and also in the preceding 
and succeeding three months, and finally any points in the previous 
history of such cases which serve to throw light on their origin. 
The returns, except for the actual period in dock, etc., are not 
absolutely complete owing to the fact that several ships have left 
the station or recommissioned and that until about June, 1905, only 
patients under treatment in Bighi are included as a rule. For the 
most prominent examples they are, however, complete, and at all 
events may be considered so for the occurrence of Mediterranean 
Fever while actually in dock, or alongside. 

Bescriplum of Docks and Surrotmdings. — Before entering upon the 
consideration of the evidence derived from these returns, it is as well 
to give a short description of the docks involved. 

Nos. 3 and 4 docks are situated, one somewhat in front of the 
other, along the northern or Senglea side of French Creek below the 
high bastion wall which separates them from the thickly populated 
streets of Senglea. These docks accommodate the battleships and 
larger cruisers chiefly. According to the returns obtained, battleships 
were docked in No. 4 26 times, 1st class cruisers 5 times, and smaller 
ships 5 times. No. 3 took 1st class cruisers twice and the smaller 
ships 16 times. 

Possible Reservoirs of Infection in the Neighbourhood. — No. 4 dock, 
being furthest down the creek, is in relation only to Senglea, the 
opposite Corradino shore being practically uninhabited. No. 3, some 
250 yards further up, abuts at its top end on Cospicua near the 
Naval stores and the market, while Senglea adjoins it alongside. 
From Senglea there were notified, in 1904, 12 cases, in 1905, 13, and 
in 1906, 11, up to the beginning of October. For Cospicua the 
figures were 21, 17, and 8 respectively. The spot maps which have 
been made out show that fully half those in Senglea and the majority 
of those in Cospicua were located at a considerable distance from 
these docks. Although it is unfortunately true that the civil 
notifications cannot be depended upon, it would be rather singular, to 
say the least of it, if this comparatively small number of cases, very 
generally distributed both as to time of year and localisation, even 
assuming the notification of only a small proportion, were sufficient 



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64 Major McCulloch, Major Weir, and Staff-Surgeon Clayton. 

to account by means of infected mosquitoes for the considerable 
outbreaks that have occurred in ships in dock, more particularly 
taking into consideration the small number of mosquitoes found 
infected in hospital wards crammed with acute cases. 

The dockyardsmen, several of whom have been shown by Shaw to 
be suffering from ambulatory Mediterranean Fever, form another 
possible source of infection, but as work in the yard ceases at 5.30 p.m., 
only Stegomyia or Acartomyia would be likely to become infected from 
them. With regard to the question of infection being conveyed from 
one case to another in the ship, not only must it be rememb«*ed that, 
while ships are in docks, cases are usually sent to hospital on the first 
sign of illness, but the chronological sequence of cases in the majority 
of instances does not suggest this mode of infection, as is shown in 
the returns. 

Nos. I and 2 docks are situated in line, wedged into a sort of 
triangle at the top of Dockyard Creek, and are absolutely surrounded 
by a crowded part of Cospicua at far closer quarters than either of 
the others. Accordingly the chances of infection should be greater 
here, but these docks are used principally for destroyers, the crews of 
which are usually hulked on these occasions, and they have not 
therefore been taken into account. The only ships of any size which 
are included in the returns are the " Harrier,'' torpedo gunboat, which 
was in No. 2 for June, 1904, no cases occurring, and the " Surprise," 
despatch vessel, in the same dock last December and January with 
a similar result, although in her case two patients sent into hospital 
for other disease contracted Mediterranean Fever while resident. 

Evidence of the Presence of Mosquitoes. — There can be no doubt that 
the domestic species are extensively bred in the houses all round, but 
in order to investigate the sources in the near vicinity of the docks 
a survey was made in June, at a time when both Nos. 3 and 4 docks 
were occupied and mosquitoes were greatly complained of by the ship 
in No. 4. The electric light connections were being laid, with the 
result that there were several collections of stagnant water around 
both docks. No larvse were found anywhere around No. 3, but from 
several pools near the other dock they were obtained, and from one 
pool Acartomyia were bred out. In addition to these artificial 
collections of water, larv» were found at the base of several of the 
hydraulic capstans, of which there are six near No. 4 and one only 
near No. 3, and in the surface-water channel at the bottom of the 
subway around the former dock which was blocked in several places, 
thus giving opportunity for water to collect. All of these proved to 
be some variety of Culex. 

On several occasions collecting boxes were sent to ships in dock to 
procure the adult insect for identification, but none were ever obtained. 

After the survey had been made, various recommendations for 



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Epidemiological Work in 1906. 65 

prevention were made in conjunction with Fleet-Siirgeoii Hardie of 
the dockyard, and these may perhaps have reduced the numbers, but 
owing to the proximity of the houses it is unlikely that* any very 
great result would be obtained. It is interesting to note that neither 
of the two ships referred to had any cases then or about that period. 
At the same time it was noted that the presence of the refuse boats 
which were kept alongside the wall between the two docks attracted 
very large number of flies in the near vicinity of the ships. 

Latrines. — There are a large number of these around both docks, and 
all seemed in very good order. Separate places are kept for 
dockyardsmen and naval people, but it is said that the latrines for the 
latter are occasionally used by the dockyardsmen. One latrine for 
dockyardsmen, close to No. 4, is placed above a store and involves 
mounting several steps, the result being that the ground at the foot 
is extensively used for urination. 

PossibUUies of Infection apart from Convection by Biting Flies, — It seems 
to be taken for granted by advocates of the mosquito theory that dock 
outbreaks are necessarily to be ^^ttributed to this method of dissemina- 
tion. From what has just been said it can be seen that contamination 
of food or drink by flies is by no means an impossibility, and that 
inoculation while cleaning latrines is equally to be considered. In 
addition, however, to these possible sources of infection, it must be 
remembered that while ships are in dock, far more patients are sent to 
hospital than usual. The cases of the " Irresistible '* and " Vulcan,'* 
quoted later, give illustrations of this fact. The explanation is that, 
while in dock, a ship is more than ever an unsuitable place for a sick 
man, the sick-bay, moreover, is often under repair, and also there is no 
latrine available on board. It is often regarded, too, as a favourable 
opportunity for sending patients for operation, while tonsillitis and other 
similar ailments ai*e apt to follow the free use of paint, etc., in the ship, 
and a prolonged stay usually means a considerable increase in the 
number of venereal cases. 

Other possibilities of infection are to be found in the presence on 
board of numerous Maltese dockyardsmen, whose ideas of sanitation 
and decency are crude in the extreme. It is not altogether infrequent 
to find that, when working down in the double bottoms, to avoid the 
fatigue of coming on deck, they have converted the part of the ship in 
which they are working into a temporary latrine. Instances of this 
have been obtained even from destroyers. 

Facts shown by the Returns of Docking referred to, — The most striking 
characteristic about these is the absolute lack of consistency in 
effects produced by docking on the incidence of the disease. As a 
general rule, perhaps, a lengthened stay in dock or alongside appears 
to be followed by a considerable number of cases, whereas a short stay, 
no matter the season, does not seem to have such effect. On the other 
(2089) / 



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66 Major McCulloch, Major Weir, and Stafif-Surgeon Clayton. 

hand, however, instances are observed, such as the 63-day stay of the 
"London" in January, 1904, where more cases occurred in the pre- 
ceding three months than during the period of stay and the succeeding 
three months together. The " Formidable," exposed to practically the 
same conditions for a similar time, provides a considerable number of 
cases, and the " Bulwark," in a much shorter time, and earlier in the 
year, provides more than either. Again, the " Formidable," exposed 
for 124 days in the beginning of 1905, shows but half a dozen cases, 
whereas the "Implacable," at an earlier period of the year, with 
132 days, shows about 20. 

The best marked instance is to be found in the " Irresistible " in 
1905, but the "Vulcan," although alongside nearly as long a time, a 
little earlier in the year, seems to have escaped more lightly than many 
ships exposed during the winter. This inconsistency in result would 
appear to point rather to something in the ship than in the docking. 

Influence of Season, — The best marked example occurred in mid- 
summer, but instances are numerous during the cold months. 
Therefore, although the tendency seems to be increased by long 
exposure in the summer, cold weathef does not exhibit any inhibitory 
influence. 

Docks Affected, — The majority of outbreaks have occurred in No. 4 
dock, but this has been shown to be used for most of the big ships. 
The experience of the "Vulcan " in 1905 shows that the danger exists 
almost if not quite as much as in No. 3 dock. 

Influence of previous Hospital Residence, — But more interesting than all 
this are the facts shown with regard to the influence of previous 
residence in Bighi. A study of the returns shows that in something 
like 50 per cent, of the cases the patient had previously and recently 
been there, and that of those who had not, a very considerable pro- 
portion indeed are oflficers. Moreover, in a number of cases they had 
actually been in hospital during all or a great part of the time the ship 
was in dock, and were therefore exposed to dock conditions for a 
shorter time than their more fortunate messmates. 

The outbreak in the " Irresistible '* provides an excellent illustration. 
This battleship, with a complement of 780 men, went alongside the 
dockyard wall on April 15, 1905, and into dock on June 19, remaining 
there until August 1, a total of 107 days, 41 of which were spent in 
dry dock. During the entire year she contributed a total of 32 cases 
of Mediterranean Fever, of which no less than 22 actually came on the 
list during this 107 days and 5 more in the subsequent three months. 
At first sight, therefore, no more admirable illustration of mosquito- 
borne infection could be adduced : a severe outbreak coincident with 
docking in a ship previously comparatively free, at the appropriate 
time of year, and, in short, all the necessary conditions. When, 
however, the history of these cases is enquired into in more detail. 



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Epidemiological Woq^Jc m 1906. 67 

a very differeoi impression is left. Thus, one man went into hospital 
for hernia five days after docking, and contracted the disease while 
resident there ; a second was living ashore at Castille Signal Station all 
the time, and was, in fact, temporarily borne on the books of the 
" Egmont." Yet another also developed the disease while resident in 
hospital for other illness, and in all probability contracted it there. 
Of the total 27 cases occurring in close relation to the period in dock, no 
less than 15 in addition to these three had recently been in hospital for 
other illness, although in two instances this was diagnosed catarrh and 
was possibly the first manifestation of fever. A sixteenth case was one 
of relapse. Of the eight remaining, three occurred among officers. 
Among the men, therefore, five cases only had no apparent oonnectio 
with hospital, and of these, one went on the list eight days after first 
going alongside, and a second 81 days after coming out of dock. Not 
only is this the case, but if the dates of residence in hospital are 
examined, it is seen that the majority of these men were there for a 
large part of the 107 days, and that the period of exposure to dock 
influences was in one as short as three days, in one 17 days, and in four 
about 20. In certainly the vast majority it was very much less than 
the rest of the ship's company. 

Fleet-Surgeon Woodwright kindly supplied a list of people sent to 
hospital for other diseases diuing the 107 days. This gives 55 men 
during this period as compared with three in January, nine in February, 
seven in March, and five up to April 15, thus giving a good illustration 
of the increased number sent to hospital which always, as previously 
stated, follows docking. Adding these together, 79 men are seen to 
have been in hospital since the beginning of the year, and of these 
15, or 19 per cent., subsequently developed fever, whereas of their 701 
longer exposed shipmates only eight, or about 1 per cent., did so during 
the same period, and three of them were officers. If this were an 
isolated incident it might be regarded as coincidence, but it is not so ; 
throughout the return practically the same thing is met with. The 
" Vulcan," for instance, sent five men into hospital before March 21, 
1906, when she went alongside, and 30 more during her stay of 84 days. 
Among these 35 men, 10 subsequently developed fever, while among 
the 414 having no recent hospital history only five, including one officer, 
developed the disease during the same period. 

If the cause were to be found in what used to be described as some 
miasmatic influence to which only the weakest succumb, this could be 
understood, but it is difficult to picture infected mosquitoes choosing 
their material in this deliberate way, and the same objection applies to 
all forms of contact infection. 

Altogether, the evidence would suggest that docking increases the 
incidence of the disease, principally by favouring residence in hospital, 
possibly in a limited number, of cases by mosquito infection or con- 
(2089) / 2 

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68 Major McCulloch, Major Weir, and Staflf-Surgeon Clayton. 

traction during sexual intercourse, more probably by contamination of 
food by flies, or inoculation by infective urine in latrines or parts of 
the ship. It suggests in addition, however, that it acts also by pro- 
ducing other illness which lowers resistance and acts as the spark to 
produce the explosion in cases where Mediterranean Fever is latent in 
the individual, or that it may do the same by the depressing influence 
of the heat and general discomfort met with while in dock, without the 
intervention of actual illness. 

V. — The Possibility of a Connection between Attacks of 
Mediterranean Fever and Sexual Intercourse with 
• Infected Persons. 

That this disease may have some etiological connection with sexual 
intercourse with infected persons is a conception that has occurred to 
more than one student of its epidemiology, the thought being prompted 
by the frequency with which it is associated with a venereal history, 
and the investigation, therefore, of the chances of such a method of 
infection has been made a part of the enquiry from its commencement. 
The results of the experiments and laboratory investigations made this 
year have shown that there is no doubt about its possibility, and it is 
left for epidemiological investigation to show whether this can be 
regarded as a frequent method of contraction. 

Evidence with regard to this may be derived from two chief sources, 
first, the study of cases in which the attack was either associated with, 
or closely preceded by, venereal disease, and, secondly, the facts as to 
the history of exposure to possible infection in those cases personally 
investigated. Two points brought out while studying the development 
of Mediterranean Fever in patients recently treated for other illness 
appear to have a bearing on the subject. Table VII, for instance, 
shows that there is a decided difference in liability between persons 
suffering from the initial and the later manifestations of venereal 
disease notwithstanding long residence in both. Another interesting 
feature consists in the large number of patients in whom the precedent 
disease is complicated by glandular enlargement, and in whom also any 
operation on the glands results in an outburst of fever. Much the 
most probable explanation of this is that these bubo cases are those 
who are on milk diet, and in whom especially debility is produced, 
but there is a remote possibility that the organism is set free from 
these glands. 

Notes have been made of 105 attacks since January, 1902, which 
were either associated with or closely preceded by the initial manifesta- 
tions of venereal disease. Of these, 13 were found on investigation to 
be relapses or sequelae, and are omitted. The remaining 92 contribute 
41 contracted in Malta, 24 elsewhere, chiefly Greece, the home ports, 
Crete and Egypt, and about 27 there, is no information available. 



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Epidemiological Work in 1906. 69 

Of those contracted in Malta, the interval between the date of 
exposure and the onset of fever symptoms was in 10 cases under one 
month, in seven under two, in 11 under three, in 11 between three 
and six, and in two over that time. 

The following cases include all those in which the evidence at all 
favoured possible connection : — 

1. H. T.— Placed on siok list June 29, 1902^ with scute gonorrhoea, and on 
Julj 26 deTeloped Mediterranean Feyer. 

2. Q-. A. — Admitted to hospital on July 2, 1902, with history of acute gonor- 
rhoea, temperature and headache following after a few days' treatment. This 
persisted in hospital, and there was positive reaction on July 17. 

3. W. C. — Contracted syphilis, primary, in Malta on June 3, 1902. On July 8 
was placed on list with temperature and a bubo. This was opened, but typical 
pyrexia persisted, although reaction negative till September 25. 

4. R. B. — £ntered on sick list December 5, 1902, with gonorrhoea, cystitis, and 
fever which persisted after admission to hospital on December 16. Reacted on 
January 22. 

5. G. v.— Admitted on April 18, 1903, with uncomplicated gonorrhoea, con- 
tracted in Malta on the 11th. Tenderness of instep complained of on 22nd, and 
next day the temperature rose. On May 1 he had pain in back and headache, and 
reacted on May 26. This man was the S.B. attendant in hospital, whose duration 
of residence before the onset of fever was the shortest of all those dealt with. 

6. A. B.— Contracted gonorrhoea on April 4, 1903, in Malta, and on April 26 
complained of pain in right ankle, hip and thighs. Reacted May 9. 

7. W. R. — Contracted gonorrhoea on March 12, 1903, in Malta, and was admitted 
to hospital on the 21st with a perineal abscess. The latter was opened and the 
temperature fell, but again rose on April 7, with shivering, although wound was 
healthy. Pyrexia persisted till April 13. Ue was discharged May 13, and onset 
of Mediterranean Fever June 19. 

8. £. M. — Contracted gonorrhoea in Malta on September 12, 1902, and was 
admitted to hospital on October 3 with epididymitis and pyrexia, which persisted 
with occasional exacerbations until 23rd. No change then till December 16, when 
onset of Mediterranean Fever symptoms. Reacted December 28. 

9. Q-. R.— Contracted gonorrhoea in Malta on January 3, 1904, and was admitted 
to hospital on the 28th with pyrexia and pain in periqeum. The temperature was 
high and had risen three days previously and he had rigors, nausea and headache. 
Nothing was found to account for perineal pain. He reacted on February 11. 

10. T. 1). — Contracted gonorrhoea in Malta on December 13, 1903. Onset of 
Mediterranean Fever symptoms on January 14, 1904. 

11. W. D. — Contracted syphilis at the end of September in Malta and was 
admitted on October 29. Two days later complained of pain in wribt and had rise 
of temperature. Reacted November 10. 

12. C. W. — Contracted gonorrhoea in Malta. Admitted June 15, 1905, com- 
plaining of pains all oyer and had gleety discharge which two days later became 
profuse. Reacted on June 20. 

18. P. W.— Contracted gonorrhoea in Malta about July 3, 1905, and reacted on 
July 11. Stated, howeyer, that he had been feeling ill since Ist. 

14. E. E. — Contracted gonorrhoea on October 4, 1905, at Malta, and was admitted 
on 16th with pyrexia. Reacted on October 20. 

16. J. S. — Admitted for gonorrhoea on June 4, 1906, and reacted on June 8. 

16. N. T. — Contracted gonorrhoea in Malta about three weeks before going sick 



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70 Major McCulloch, Major Weir, and Staflf-Siirgeon Clayton. 

with Mediterranean Ferer, and noticed it two or three days after admission. 
Had been feeling ill, however, otf and on for three weeks. 

17. G. P.— Contracted gonorrhoea in Malta about middle of October, 1903. This 
was followed by orchitis and pains in hip and shoulders, and by temperature afc 
nights. Admitted to hospital on November 17, and gave good reaction at once. 

The following coses are qnoted to show that the development of Mediterranean 
Fever symptoms is not confined to patients whose venereal d if ease is contracted in 
Malta :— 

1. T. T.— Contracted gonorrhoea on May 3, 1903, at Portsmouth and put on list 
on May 11. Discharged to Malta hospital from " Porpoise" on May 21. Rise of 
temperature and pain along cord on May 29 and reacted on May 30. 

2. J. H. N.— Contracted syphilis primary and gonorrhoea on December 18, 1903, 
at Canea, and on January 15, 1 904, developed symptoms of Mediterranean Fever. 

The above cases include all which could be found in which the dat^ 
were at all suggestive of a simultaneous contraction of the two 
diseases, and it will be seen that the evidence could not, by the 
greatest stretch of the imagination, be called an3rthing but inconclu- 
sive, and, as they were all treated in Bighi Hospital, is in the large 
majority far more suggestive of their having been contracted there. 

Fads Elicited from the Study of Individual Cases with Regard to the 
Contraction of the Disease during Sexual Intercourse. — Of 59 persons in 
whom it was possible to obtain information on this point, 42 denied 
that they had ever had intercourse on the station, six admitted to 
having done so, but not for months, four had recently done so, but in 
places other than Malta, while seven admitted recent intercourse in 
Malta itself. In one of these latter cases the patient remembered 
having been severely bitten on the eyelid by some insect, but this was 
the only case in which such a history could be obtained. The 
intervals varied from three to six weeks before onset. 

This is not a point upon which negative evidence can be regarded as 
very trustworthy, but taking it for what it is worth, it is not sugges- 
tive of any large number being contracted in this way. 



Section B.-PREVENTIVE MEASURES INSTITUTED AGAINST 
MEDITERRANEAN FEVER IN THE NAVY. 

I. Methods of Prevention Undertaken in 1906. 

Protection from the Attacks of Mosquitoes. — The experiments and 
investigations carried out in 1905 by the members of the Commission 
had been very suggestive of a mosquito-borne infection, and after the 
arrival of the military members of the Commission this year it was 
decided on their recommendation to isolate all military Mediterranean 
Fever patients in the long ward of Valletta Hospital, and to render 
this mosquito-proof. 

It has already been stated that systematic oiling of tanks, etc., and 
the use of mosquito nets had been for some time an established 



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Epidemiological Work in 1906. 71 

routine at the Naval Hospital, while isolation had been adopted since 
1902, but it was thought that if, in addition, one of the wards 
containing patients suflfering from other illness, and which had recently 
contributed several cases of the disease, were treated similarly, it 
would act as a useful control to this experiment of protecting the 
infective cases from mosquito attack in the military hospital. 
Accordingly, on April 26, this suggestion was submitted to the 
Deputy-Inspector-General, and was forwarded by him to the Admiralty, 
and subsequently approved, but, fortunately, up to the end of October 
the work had not been commenced, so that any diminution in incidence 
which has occurred in the Navy cannot in any way be attributed to 
this proposed experiment. 

Disinfection of PcUients* Effects, — On May 4 I made the further sug- 
gestion that the effects of all patients, whatever their disease, 
admitted to hospital, should be disinfected, in order to prevent the 
possibility of tmdiagnosed cases being overlooked, but this measure 
was foimd to be impracticable, and it was likewise impossible to carry 
out on board ship processes akin to the disinfection and evacuation of 
barrack rooms introduced this year. 

Control of MUk Supplies. — From a naval point of view, therefore, the 
only prophylactic measures which have been undertaken consist in 
those directed to the more efficient control of the milk supply. 

So far as the Naval Hospital is concerned, the first step in this 
direction was taken by Staff-Surgeon Whiteside. Suspecting from the 
condition of the milk on several occasions, after issue to the wards, 
that it had not been properly sterilised, he had it intercepted on its 
way from the kitchen on each day from March 31 to April 7, 1906, 
and a sample taken with all needful precautions, and conveyed to the 
laboratory. On March 31 and April 1 and 4 an organism corre- 
sponding in morphological and cultural characteristics to Micrococcus 
melUensis and clumping with Mediterranean Fever serum was success- 
fully isolated On this being reported to Deputy-Inspector-General 
Bentham, the requisite measiu'es were at once taken by him to ensure 
that there should in future be no possibility of neglecting the instruc- 
tions, already existing, with regard to sterilisation of milk, and it may 
be regarded as practically certain that since this date there has been 
no repetition of this. 

On May 4, as information had been obtained that some of the Sick 
Berth Staff had been drinking unsterilised milk in their own quarters, 
notwithstanding instructions to the contrary, I wrote to the Deputy- 
Inspector-General drawing attention to the fact that only the milk for 
the hospital itself was sterilised in the hospital kitchen, the supply for 
the various residences and quarters being sent to their own kitchens 
and, presumably, sterilised there. In this letter it was urged that 
this multiplication of sterilising stations added greatly to the chances 



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72 Major McCul^och, Major Weir, and Staflf-Surgeon Clayton. 

of some of the milk escaping, and the suggestion was put forward that 
the sterilisation should be carried out at the main gate, and no milk 
admitted into the grounds until this had been effected. 

This was approved in principle, though with some alterations in 
detail, and was later carried out, but from May 21 to June 1 any such 
procedure was unnecessary owing to a strike of the goatherds, which 
rendered obligatory the use of preserved milks. 

As a further guarantee of sterilisation I suggested on May 16 the 
routine use in hospital of the ortol and peroidde of hydrogen test, 
which had been mentioned to me by Dr. Eyre, and on the return of 
the fleet on May 23 from the Pirceus its use was likewise recommended 
in all ships through the P.M.O. of the flagship, and a general 
memorandum was promulgated to that effect by the Commander-in- 
Chief. 

On July 3 the Deputy-Inspector-General had made arrangements for 
the further examination of the goats supplying the hospital, and for 
the issue of identification labels for them, but after some 60 samples 
had been taken the goatherds objected to anything further being done 
and returned the labels, whereupon the supply was very rightly 
discontinued, and preserved milk has been used exclusively ever 
since. 

MUk in the Fled, — During the absence of the fleet on manoeuvres, in 
June and July, I made an attempt to examine into the sources of 
milk for officers' messes, and the enquiry was started with two large 
dairies which supply the greater proportion of the ships. The system 
upon which both of these obtained their milk was, judging from the 
description given, of the most unsatisfactory nature. For the regular 
supply apparently a certain small number of goat or cow owners were 
called upon, but for any extraordinary occasion, such as the arrival of 
the fleet, milk was often obtained from quite casual sources. One 
of these two dairymen entirely failed to persuade any of the people 
who supplied him to allow even samples of milk to be obtained. 
After much trouble and one ineffective visit consent was obtained 
in the case of one owner of a small herd at Sliema who helped to 
supply the second dairy. Here, however, of the total of 20 goats half 
were said to be pregnant or, for other reasons, not yielding milk, an 
assertion which could not be tested, as the animals were located in 
a small back street, and so intermingled with other herds that it was 
impossible for anyone but the owner to distinguish between them. 
The 10 samples obtained were examined by Zammit's test, and one 
which gave a good reaction was plated out in the laboratory and 
reported to have yielded Micrococcus jnelitensis. 

Accordingly, on the return of the fleet on August 4, I sent a letter 
to the P.M.O. of the flagship for submission to the Commander in- 
Chief, detailing the result of these investigations and the exceedingly 



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Epidemiological Work in 1906. 73 

unsatisfactory conditions under which milk was supplied to officers' 
messes, and also giving a short summary of the facts known up to that 
time, which suggested milk as the vehicle of infection. 

The following alternative suggestions were also submitted : — 

(1) The absolute substitution of preserved for fresh milk in the 
fleet. 

(2) The prohibition of the use in the fleet of milk obtained from 
owners who refused to brand their animals in an unmistakable manner, 
to give samples of milk or blood at any time, and to milk them only 
in certain places and certain times to facilitate inspection by a special 
officer. 

(3) The provision and entire control of a special milk supply by the 
naval authorities. 

On the arrival of the fleet on August 4 the Commander-in-Chief 
repeated the order that all milk obtained in Malta was to be boiled. 
It was then to be tested by the ortol test, and the completion of this 
process to be signalled each morning to the flagship. 

Ice Creams, — It was discovered on the return of the fleet in October, 
owing to a question being asked by the Commander of one of the 
ships as to the possibility of infection through ice creams, that these 
were in some cases being purveyed on board by hawkers. The 
attention of the P.M.O. of the flagship was therefore drawn to this, 
and the experiments made this year in the laboratory, which would 
suggest that these must be regarded as under suspicion, were referred 
to, with the result that a general memorandum was issued prohibiting 
their sale on board and warning officers and men that their consump- 
tion was attended with some degree of risk. 

From this account it can be seen that in the Naval Hospital the milk 
cannot be said to have been certainly sterilised before April 9, and 
that the Sick Berth Stafl* and residents may have taken small quantities 
unsterilised for a week or two later. With regard to the fleet supply, 
the ortol test, when made use of between May 23 and June 5, showed 
that in two ships at least milk has not been boiled as supposed, but 
ever since the departure of the fleet from Malta on June 5 it is 
probable, from the increased attention paid to it and the use of this 
test, that there have been very few, if any, occasions on which it has 
escaped sterilisation. 



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74 Major McCulloch, Major Weir, and Staflf-Surgeon Clayton. 

II. — Incidence of Mediterranean Fever since the Foregoing 
Measures were Instituted. 

Incidence in the Fleet. 

Table XXIV. — Giving the Admissions per Month since January, 1902, 
excluding Relapses. 



Month. 



1902. 1903. 



1904, 



1905. 



In I In 
Bighi. I fiighi. 



In I In 
Bighi. Bighi. 



1906. 



Others. 



In 
Bighi. 



Others. 



January 7 

February 8 

March ' 26 

April i 27 

May 47 

June 34 

July 27 

August 22 

September 26 

October 32 

NoTembcr | 22 

December 1 16 



18 
20 
30 
20 
33 
45 
12 
4 
25 
18 
29 
21 



27 
28 
24 
28 

4 
15 
22 
12 

8 
44 
17 
17 



17 
7 
17 
29 
31 
46 
30 
16 
4 
12 
24 
14 



7 
1 
20 
9 
2 



20 


4 


21 


11 


16 


6 


22 


3 


19 


5 


8 


15 


4 


8 


3 


4 


2 


— 


3 


1 


1 


-- 


~~' 


~~" 



In connection with this table it must he first of all noted that 
the fleet has this year been very considerably reduced, and further, 
that one or two of the larger ships have spent some time in England 
while recommissioning, and have returned with almost new crews. 

In the second place, most ships have been absent from Malta for an 
unusually lengthy period. From February 9 to April 19, May 4 
to 23, June 5 to August 4, and from August 13 to September 30, 
almost the entire fleet was absent. In 1905 the majority of the fleet 
made a short cruise early in the year, and again left on June 17, 
returning about August 26 and remaining till September 6, when 
another cruise was made, lasting till September 30. 

The diminution in the number of cases therefore to some extent 
supports the statement made by Shaw to the effect that Malta is the 
headquarters of the disease, and that in the Navy very few cases are 
contracted elsewhere. 

Nevertheless there is considerable reason for supposing that these 
two facts by no means explain the total decrease. 

Incidence among Persons Constantly Itesideni in Malta. — If, for instance, 
the figures for the stationary ships and hospital on the one hand and 
the dockyard employees and the naval Maltese admitted to Bighi on 
the other are contrasted, it is seen that the former, to whom the 
precautions above detailed with regard to milk apply, show a very 



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Epidemiological Work in 1906. 



75 



decided reduction in the number of cases of Mediterranean Fever, 
whereas the latter, among whom no special measures have been 
adopted, show no diminution. 

Table XXV. — Contrasting the Monthly Occurrence of Cases in the 
Hospital and Stationary Ships, and the Dockyard Employees 
and Naval Maltese admitted to Bighi for 1905 and 1906. 



Month. 



Hospital and | Dockyard 
I stationary ships.* | employees.f 



January i 2 

February 

March i 8 

Aprd ' 1 

May 8 

June ' 9 

July 5 

August j 3 

September 1 

October 1 1 

November \ 3 

December 




Naral 
Maltese.f 



1905. 1906. 



* Milk precautions adopted after April, 1906. 
t No special milk precautions. 

X Both these men were living ashore and yictualling themselres. 
case a distinct milk history was obtained. 



In the last 



Pointing in the same direction is the fact that since the return of 
the fleet on September 30 to January 13, 1907, only six cases have 
been notified from Malta, Gibraltar, and the home hospitals. Of two 
which occurred in October, one, a warrant officer of the " Bulwark," 
was originally admitted with symptoms of pleurisy and, although he 
gave a reaction shortly after, was regarded as a doubtful case. The 
second, a domestic, lived ashore and gave a definite milk history. A 
third case, occurring in November, is the man referred to in 
Table XXV as having been victualling himself ashore and as also 
giving a definite milk history, and the fourth case, which likewise 
developed in November, was an officer of the " Surprise " who went 
straight home in the " Maine." The date of onset in his case is 
given from Haslar as July 21. Two cases have been notified from 
the home hospitals, one being a man belonging to the '* Diana" 
whose illness commenced in October, and the second a Ch. S. B. 
steward from Bighi who has been frequently sick with " rheumatism " 
and the onset in whose case is indefinite. He was admitted to Haslar 
in November. 



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76 Majof McCuUoch, Major Weir, and Staff-Surgeon Clayton. 

A third fresh case was also notified from Haslar, but this illness is 
stated to have commenced in March, when he had been three months 
imder treatment for bubo in Bighi. With the exception of the S. B. 
steward these cases are included in Table XXIV under the month of 
onset. 

It will be seen from Table XXV that the dockyard and Maltese 
contribute no less than 10 of the cases since June, and as a matter of 
fact the persons under treatment for this disease in Bighi have for the 
few months preceding November been drawn almost exclusively from 
these sections of the Naval population. 

When contrasting the incidence of the disease this year as compared 
with 1905, it must be remembered that the figures for the present 
year include cases which have developed while at home or on passage 
there, and also cases not sent to hospital, whereas in 1905, except in a 
very few instances, only those cases returned from Malta and 
Gibraltar are taken into account and practically none which have not 
been sent to hospital. Comparing the cases only which have occurred 
on the station, a total is given of 174 from June to December, 1905, 
as opposed to 47 for the same period in 1906. 

But there is yet another way in which the cases this year may have 
been over-estimated, inasmuch as there are quite a number included in 
the returns in which there is justification for some doubt either as to 
the diagnosis or as to whether the attack was really the first 
manifestation of the disease. This applies to four cases occurring in 
one ship at the end of June and one in another ship about the same 
time, in which no reaction was present very shortly after discharge 
following a very brief illness. These cases are further referred to on 
p. 84. Two cases in June were diagnosed on clinical grounds alone, 
and one was admitted to be doubtful. An eighth case had been 
constantly on the list at intervals for months with rheumatism or 
febrile attacks. A ninth, although he gave a reaction in his ship up to 
1 in 20, showed no trace either at Gibraltar or Plymouth hospital, and 
was returned from both as Fever, S. C. Another man had been 
notified from his ship as giving a positive reaction during a short 
febrile attack in July, 1905, and may possibly, therefore, have been a 
relapse. 

Incidence of tlie Disease in Bighi Hospital. — Even more noteworthy 
than all this, however, is the alteration that has taken place as regards 
the incidence of the disease in the Royal Naval Hospital at Bighi. It 
has been shown that since April 9 the sterilisation of milk may be 
regarded as reliable. Chart 5 and Table VIII show that, of the 
patients sufiering from other illness in Bighi during the first quarter 
of 1906, 28 subsequently, within three months of discharge, developed 
Mediterranean Fever, but that this has not occurred in a single person 
who has been admitted since. As a matter of fact, among patients 



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Epidemiological Work in 1906. 77 

resident in Bighi and subsequently developing the disease, no one 
shows a later date of discharge than April 16, seven days after the 
more stringent regulations with regard to sterilisation came into force, 
and in that particular case symptoms developed within three days. 
No other individual suffering from an attack has given a history of 
previous residence subsequent to that date, and, simultaneously, there 
has been a total cessation of cases definitely contracted while still in hospital. 

This contrasts markedly with 1905 and the first quarter of 1906. 
Yet Table VIII, which illustrates this, also shows that, although the 
number of cases of other illness was comparatively small, there were 
at least quite as many long residence cases admitted in the second as 
in the first quarter and, given corresponding conditions, a number 
should have contracted the disease. Nor can the diminution in the 
amount of infective material be put forward as the explanation, since 
Chart 5 shows that in April and May, although no cases were 
contracted, there were quite as many Mediterranean Fever cases in 
residence as in the earlier part of the year. 

Although no definite case has developed in Bighi since the first 
quarter of this year, the following three cases are quoted because they 
represent the nearest approach to it that has occurred; and also 
because they illustrate the fact that, as stated on p. 246, a reaction may 
be present in Englishmen who have never shown symptoms. 

R,P., stoker, was admitted to Bighi on September 5, 1906, with 
gonorrhoea, which was contracted at the Marsa on September 1. He 
showed no symptoms suggesting fever until the 28th, 22 days after 
admission, when he had headache and temperature lasting for two 
days. On blood examination, he was found to give a good reaction in 
a dilution of 1 in 10, but not in any higher dilution, and this condition 
persisted during the numerous blood examinations made before he was 
discharged, but without any recurrence of symptoms, and there has 
been no sign of illness up to the end of the year. He was in hospital 
during 1 905 for a considerable time. Although it cannot be denied 
that this was possibly Mediterranean Fever, the progress of the case 
and the nature of the reaction is decidedly against this view and the 
medical officers of the hospital did not regard it as such. Another 
man admitted about the same time with typical symptoms of 
gonorrhoeal rheumatism and iritis, whose blood was sent up more as 
a matter of routine than anything else, was found to present 
a precisely similar reaction. In this case there was no question of 
contraction in hospital, and the illness was also in all probability not 
Mediterranean Fever. An ofl&cer suffering from septic poisoning 
showed a similar reaction, but in his case a recent attack accounted for 
it. It cannot be said that these three afford any evidence for 
retracting the statement made above, that no definite case has been 
noticed since April. 



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78 Major McCuUoch, Major Weir, and Staff-Surgeon Clayton. 

Another point in favour of the view that the measures instituted 
this year have had an effect on the incidence of the disease is that 
while the Army ratio has fallen, no marked alteration is shown up to 
September among the civil population for whom no corresponding 
preventive measures have been taken. 

Concltisio7u — The reductions would therefore seem to have been 
greater than appears at first sight and the history, especially as 
regards Bighi, points strongly to the precautions taken in connection 
with milk as mainly contributing to this, while the evidence derived 
from a comparison of the ratios in the Service and civil populations 
argues in a like direction. 

SECTION C— PEKSONAL INVESTIGATIONS. 

I. — The Prevalence of Mediterranean Fever in Separate 
Ships During 1906. 

Battleships. — ^All the battleships on this station belong to the 
same class and possess several characteristics in common. Accommoda- 
tion for the men is not particularly good, and in bad weather they 
have to sleep in the lower parts of the ship where ventilation is very 
defective, but in this respect none of this class are as badly off as 
cruisers like the " Leviathan," which suffers far more severely from 
overcrowding. The men's latrines are on the upper deck, but the sick 
bay W.C., into which most of the infective excreta are emptied, opens 
directly out of the sick bay. 

Milk Supply, — While at Malta, fresh milk was supplied to all these 
ships for officers' messes, and in the case of the ^'London," 
" Implacable," " Irresistible," and '* Venerable " for the sick bay also. 
The " Bulwark " and] " Formidable " used tinned milk in the sick bay, 
while the other two ships, the " Queen " and " Prince of Wales," left 
for England to recommission early in the year, and were for so short 
a time on the station that they are not taken into account. There 
were strict instructions with regard to the boiling of milk in all cases, 
but in at least one ship, when the ortol test was first made use of 
in May, milk, supposed to be boiled, both for gunroom and wardroom, 
was shown to give the characteristic reaction. 

Disinfection in Cases of MedUerranmn Fever. — The process adopted 
varied greatly in different ships. In the "Irresistible," which 
contributed more cases than any other ship, not only were the excreta 
and also the sheets and bedding disinfected, but the w.c. was 
fumigated, while in the "Implacable," which also contributed 
a considerable number of cases, no very special precautions were taken 
in this direction. In the " London " everything was disinfected, and 
in the " Bulwark " only the excreta and sheets, etc., but not beds. 



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Epidemiological Work in 1906. 79 

Hawkers of food stuffs were only allowed in one of these ships and 
in that case it was confined to fruits and aerated waters. 

ffJLS, ''Bulwark,'^ — This ship is the flagship of the Commander-in- 
Chief and has an average complement of about 829 men; she was 
recommissioned on January 3, 1905, and most of her crew therefore 
have been from one to two years on the station. 

Movements, — She was continuously alongside the dockyard wall or in 
dry dock in Malta from October 31, 1905, to February 5, 1906, and 
five days later left with most of the fleet for a cruise during which 
she touched at Gibraltar, Genoa, Aranci Bay, Naples, and Corfu, and 
returned to Malta on April 19. From May 2 to 5 she went to Platea 
and left that place for Phalerum Bay on the latter date owing to the 
Turkish frontier dispute, returning again to Malta on May 25 and 
remaining until June 5, when she again left with the rest of the Fleet 
for the grand manoeuvres, her headquarters then being at Gibraltar. 
Another short stay was made at Malta from August 4 to 13 and 
a cruise up the Adriatic and to Argostoli followed, a final return to 
Malta for the winter being made on September 30. 

Incidence of Cases. — Three first attacks and also three relapse cases 
occurred in January, one in March, three in May, one in Jime, one in 
July, and two in October. The principal point of interest about them 
consisted in the grouping that was exhibited. One patient, who 
became ill on January 19, belonged to No. 43 Mess, a second three 
days later came from No. 47, two tables further along on the same 
side of the ship, but the first of these was in Bighi, from November 13 
to December 8, with gonorrhoea, and probably contracted the disease 
there. Another, on March 19, belonged to No. 45, situated between 
these two, and this man had been in hospital from February 1 to 9 
with what was diagnosed as influenza, but may have been the initial 
manifestation of Mediterranean Fever, as he had given a doubtful 
reaction in 1 in 10 dilution while there. A second man from Mess 45 
went sick on May 8 ; he also had been in hospital from January 24 to 
February 9, but in this case with ulcer of the foot, and had very likely 
contracted the disease there. On June 2 yet a third man from 
Mess 45 became ill. One curious feature about these cases was that 
two showed unusual symptoms in the shape of purpuric eruption and 
swelling of the ankles. None of them had been ashore more than 
once or twice in Malta recently, but up to February 5 the ship had 
of course been alongside the dockyard. The marked grouping is 
certainly suggestive at first sight of contact or mosquito-borne 
infection, but, with regard to the latter, the sleeping billets of these 
five men were widely separated, and in two cases at least there were 
decided possibilities of infection while in hospital. With one 
exception the three relapse cases mentioned were far removed from 
these messes, and this exception was in a mess on the opposite side of 



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80 Major McCuIloch, Major Weir, and Staflf-Surgeon Clayton. 

the ship. All the affected messes were close alongside the seamen's 
galley, but the ofl&cers' galley where the fresh milk would be taken was 
further aft in the next compartment. 

It is likewise interesting to note that from the end of May, when the 
ortol test was adopted, up to December 7, only four cases occurred. 
Three were living ashore, one an officer, two domestics, and the fourth 
(also an officer) appears to have been a somewhat doubtful case. 

The apparent dependence on stay in Malta is also to be noted, no 
case having occurred after July 17 until return in October. 

HJLS, " LondonJ* — This ship has an average complement of about 
740, and as she was commissioned on April 6, 1905, the majority of her 
crew are also in their second year on the station. 

Movememis, — On January 4 she left Malta for a cruise to Genoa, 
Civita Vecchia, and Naples, arriving at Malta again on January 31, and 
next day going alongside the dockyard, where, or in dook, she remained 
until April 24, when she moved out to moorings in Grand Harbour. 
From May 5 to 23 she accompanied the fleet to Phalerum Bay, and 
from June 5 to July 28 to Lagos for manoeuvres. On the latter date 
she again returned to Malta and remained till August 6, when she left 
for the Adriatic cruise, finally returning on September 30. This ship 
was, therefore, during the earlier part of the year, longer exposed than 
the majority of the others to the possibility of infection at Malta. 

Incidence of Cases. — The first case of the year fell ill on January 24 ; 
he had recently been in hospital from October 14 to December 1 with 
sore throat and rheumatism. The second case followed on February 4, 
three days after going alongside the dockyard. Nine days later a third 
man first felt ill, and on February 17 a fourth. The next case began 
exactly a week later, on February 24, and the next, a marine gunner, 
on March 1 3. Both these latter were discharged cured at the beginning 
of April and rejoined the ship. The next case that occurred had been 
in hospital from January 1 to February 9, and was put on the list on 
March 31. On April 24 another marine gunner began to feel ill; he 
had been messing with the man already mentioned as having been 
discharged cured from hospital since April 6. A Maltese stoker who 
lived ashore at Cospicua began to ail about May 12, and the next case, 
an ordinary seaman who had been in hospital for two months \mtil 
April 7 with psoriasis, commenced to feel ill on May 14. Since that 
time there have only been two rather doubtful cases and one attack in 
a Maltese domestic. 

The two doubtful cases were the captain*s steward — who was sick on 
board from July 18 to 28, and gave a reaction with a dead culture, but 
in whom no trace of a reaction could be obtained when his serum was 
examined on August 1 in the Commission Laboratory — and a midship- 
man, who was sent on June 23 to Gibraltar Hospital for appendicitis, 
and was invalided as Mediterranean Fever, but the diagnosis was made 
on clinical grounds, no reaction having been obtained. 



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Hpidemiological Work in 1906. 81 

The Maltese domestic became ill a few days after the ship left Malta 
in August. 

Of the 13 possible cases, therefore, three had recently been in 
hospital and two were Maltese, while of the others two were doubtful 
Six occurred in close relation to the period during which the ship was 
in dock or alongside, of whom only one had been in hospital. Two of 
the others, however, were marines, and it is to be noted that the 
marines of this ship were at Ghain Tuffe Eifle Bange from February 
12 to 27 and March 3 to 12, and that one of the two attacked had 
been sleeping there up to March 10. Four of the 13 patients attacked 
were marines, but these cases were widely separated in point of time, 
and with the one exception already noted there was no attempt at 
grouping. 

Possible Sources of Infection. — The blood of 28 of the permanent 
Maltese was kindly sent by Fleet-Surgeon Hadden to the laboratory,, 
and one was found to react up to 1 in 50. A man who was the- 
manager of the canteen began to ail about April 1, and eventually died 
at his home ashore of what was returned as Mediterranean Fever ; he 
may have been ill for some time on board. The blood of both the men 
who were discharged cured from hospital was also examined, but 
neither gave a reaction. 

H,M,S, " Implacable" — This ship has a complement of 742 men and 
arrived on the station on September 17, 1904, after recommissioning, 
and since that time has had over 20 cases of Mediterranean Fever, so 
that she has been one of the ships more severely attacked* 

Mavemenis. — She arrived at Malta from Corfu on January 5, 1906, 
and remained at moorings in Grand Harbour until February 10, with 
the exception of 14 days in dock, from January 25 onwards, when she 
left for the Lagos cruise. She returned to Malta, however, on March 13 
to have her fire control fitted, and was in dock and alongside for that 
purpose for 24 days. On April 6 she left for Corfu, returning on the 
19th, and during this trip took away the six dockyardsmen who were 
at work on fire control. She only remained four days on this occasion 
and then went to Platea until May 5, when she accompanied the fleet 
to Phalerum Bay. On her return she spent five days at Marsa Sirecco,. 
and finally reached Grand Harbour on May 30. On June 5 she again 
sailed for the manoeuvres, and while absent on this occasion proceeded 
to England to recommission, and since that time has contributed no- 
cases of Mediterranean Fever, so that all remarks deal with the old 
commission. 

Incidence of Cases, — ^Four cases were admitted from this ship on 
January 1, of whom one had just previously been in hospital with 
rhetunatism, and one was a Maltese domestic. The onset in all waS' 
about the middle of December. A fifth case became ill on January 14,. 
and another on February 20, but this latter patient had been discharged 
(2089) ^ 



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82 Major McCuUoch, Major Weir, and Staff-Siirgeon Clayton. 

from hospital on December 13, after enteric, and had probably con- 
tracted the disease there. He was an engine-room artificer. While 
the ship was at Malta, after March 13, two men, one the sick berth 
steward, suffered from attacks, the diagnosis being later verified by 
blood examination in the Commission Laboratory. The sick berth 
steward did not go on the sick list. Both had quite recently been in 
hospital. On the return of the ship from Corfu on April 19, five more 
cases were sent to hospital, but one of these was a relapse in a man 
who had rejoined the ship on March 13. Three of the remaining four 
had been recently in hospital, and probably contracted the disease 
there, the dates of onset being March 24 and April 3 and 16 respec- 
tively. The fourth case was an artificer belonging to the same mess 
as the first one, and the date of onset in his case was also April 16. 
Two gun-room artificers next became ill on April 23 and 26 respec- 
tively ; the second had, five months previously, been in hospital with an 
ulcer. 

Of the 14 cases in this ship, therefore, seven had been in hospital 
within three months of other illness, two were officers, and one a 
Maltese. Two belonged to the gun-room and two to Mess 55, one 
each to Messes 57, 59, and 61. The others were widely scattered. 

Possible Sources of Infection, — The relapse case was on board from 
March 13 to April 19, and after his second admission on that date his 
urine was plated out on more than one occasion both at Bighi and in 
the Commission Laboratory, but without recovering the Micrococcus. 
Two other men were suffering from the disease on board, one becoming 
ill on March 13, the other on March 17, and one of these was not on 
the list. Six dockyardsmen were on board, living in a casemate, from 
April 6 to 19, and had been working on board since March 13. The 
blood of five of these was obtained, and one gave a reaction in both 
1-per-cent. and 2-per-cent. dilution, but not a very marked one, and one 
other in only 1-per-cent. dilution. Eight dockyardsmen, including 
three of the preceding, were working on board from April 21 to 
May 29, but none of these gave a positive reaction. Of 1 1 who were 
left in the ship on June 5, all but two had been included in the previous 
parties, the man who gave the reaction in both dilutions being one of 
them. Neither of the two fresh men reacted. Twenty-eight of the 
permanent Maltese in this ship were also examined and one only was 
found to give a reaction, this being the domestic who was admitted to 
hospital for Mediterranean Fever on January 1. 

It is evident, therefore, that in this ship there were an unusually 
large number of possible sources of infection, while a certain degree of 
grouping was noted, but the fact that so large a proportion of those who 
were not officers or Maltese had recently been in hospital rather discounts 
the value of this as an evidence of contact infection. The case which 
pointed most strongly in this direction was the second artificer, who 



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Epideniiologiccd Work in 1906. 83 

had been working with the party of doGkyardsmen, two of whom 
reacted. 

H,M,S, " Irresistible.^* — This ship, which also has an average comple- 
ment of about 740 men and was in her second year on the station, 
«ii£fered during 1905, as already detailed at p. 66, more severely than 
any other battleship, principally during a long stay in dock. . 

Movemenls, — From January 1 to 27, 1906, she was cruising between 
Patras, Platea, and Corfu, and on the latter date arrived at Malta, 
where she remained moored in Grand Harbour until February 10. 
She accompanied the rest of the fleet for manoeuvres at Lagos, and 
later went with the flagship to Genoa, Aranci Bay, Naples, and Corfu, 
returning to Malta on April 19, and remaining in Grand Harbour till 
April 30, when she left to carry out firing, and went on with the others 
to Phalerum Bay. She returned on May 22, but left at once for 
Marsa Sirocco for two days, and on coming back to Grand Harbour 
went into dock from May 28 to June 1. Like the other ships, she left 
4&gain on June 5, but returned on July 29 and once more went into 
dock for a further period of six days, leaving on August 6 for the 
fiame cruise as the flagship. It wiU be seen, therefore, that her men 
liave had comparatively few opportunities of leave in Malta since 
February. 

Incidence of Cases, — Two patients, a warrant officer and a stoker, 
became ill on February 20, 10 days after leaving Malta, and a marine 
gunner the next day. All three had been quite recently in hospital, 
and probably contracted the disease there. Three more were sent to 
hospital on her return to Malta on April 19, one of these being 
a relapse case, and the other two having become ill on April 1 and 16 
respectively. Both had been in hospital, one until the ship left Malta, 
while the other had not been discharged till February 19, and had 
waited some time in the *' Egmont." In the first case, therefore, the 
onset occurred some 40 days after departure from Malta. The next 
case, an officer who had been in hospital for operation on the knee 
joint, first felt ill on April 12, a month after discharge; he had been 
living ashore during the interval. 

Up to this time, therefore, every case, without exception, had recently 
been in Bighi suffering from other illness, but after this, although this 
ahip was the only one which returned any considerable number of 
cases subsequent to the departure of the fleet on June 5, only one 
of these had previously been in hospital, and he before April. A 
marked grouping was, however, met with in this second series of cases. 
The first of these, a chief petty officer, began to feel ill on June 2, but 
was not placed on the list till after she left for the cruise. A second 
man, belonging to Mess 26, which was separated from the chief petty 
officers' mess by a water-tight compartment, communicating by a door, 
first began to ail about June 6. An able seaman, living on a different 
(2089) fj 2 



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84 Major McCulloch, Major Weir, and Staflf-Surgeon Clayton. 

deck, was the next to feel ill, the onset in his case being about 
June 23, and he gave a history of hospital residence from February 3^ 
to March 21. A fourth man, belonging also to Mess 26, first had 
symptoms on June 26, and next day a chief petty officer with his mese 
in quite a different part of the ship also began to aiL The day after 
this a chief stoker, who had up to Jiuie 21 also belonged to Mess 26, 
was put on the list, but this man said he had been feeling off colour 
for months. The last man belonged to a different mess altogether, and 
his symptoms began on July 14, or rather more than a month after 
leaving Malta. 

Since that time only one case has occurred, the sick berth attendant, 
who first complained on August 8, two days after leaving Malta 
on the next occasion. This man was on the staff at Bighi until' 
May 4. 

Mess 26 and the chief petty officers' mess next to it were closely 
adjacent to the sick bay, so that of the eight cases occurring after 
June 5 no less than five came from one very limited portion of the 
ship. Propinquity to the sick bay offers, therefore, a possible source 
of infection, but the man who first felt ill did not go on the sick list 
as soon as the second, so that two out of the five occurred before there 
was any known source of infection there. 

It is also a curious fact that four out of these eight cases were only 
ill about three weeks, and that when their blood was examined in the 
Commission Laboratory on August 1, very shortly after their discharge 
from the sick list, not one of them gave the faintest trace of a reaction. 
Surgeon Macleod, who was kind enough to give information on the 
subject, states that the symptoms were in all cases quite characteristic, 
that the reaction was undoubted in each case, and was repeated more 
than once, and that a control showed no reaction. The culture was, 
however, an old one, and as none of the patients have since shown any 
sign of recurrence of symptoms, some small amount of doubt as to the 
nature of the illness may perhaps be permitted. Anything suggesting 
criticism of the results obtained by competent observers who have,, 
moreover, had the advantage of studying the actual symptoms is to be 
avoided, but as the culture used was an old one it may at least 
be regarded as rather a curious coincidence that no less than four cases 
occurring at the same time should be of such short duration, have no 
sequelae, and within a month fail to give a trace of agglutination even 
in low dilutions. At the same time the fact that the remaining oases, 
which were more severe and necessitated invaliding, have all been 
confirmed by examinations made at the home hospitals must be 
regarded as evidence in favour of the four specified above being cases 
of the disease. 

There was another possible source of infection in this group of cases, 
inasmuch as several dockyardsmen who were in the ship during this^ 



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Epidemiological Work in 1906. 85 

particular cruise fitting fire control were accommodated in the case- 
mates just alongside these messes. Accordingly, on the return of the 
fleet, the blood of six out of the total of seven of these men was 
obtained and tested, but no reactions were obtained. The blood 
of 28 of the permanent Maltese on board was also obtained and tested, 
and one was found to react. Of the five men composing the group, 
two slept in their messes, and the sick berth attendant in the sick 
bay, the rest elsewhere. Once again, therefore, the evidence, on the 
whole, points to some cause operating in the da3^ime rather than at 
night. 

H.M.S, " VenerableJ' — This, the flagship of the second in command, 
has been on the station since September, 1905, and her average com- 
plement is about 770. 

Movements. — She was at Naples on January 1, 1906, whence she 
proceeded fiiA Port Augusta to Malta, arriving on January 9, and 
remaining at moorings in Grand Harbour till February 10. On that 
date she left for manoeuvres at Lagos, but did not return witli the rest 
•oi the fleet, as she proceeded on March 8 to* Chatham to receive a new 
admiral. She left England on March 30 and arrived at Malta, after 
calling at Gibraltar, on April 7. Three days later she went into 
No. 4 Dock, and remained there or alongside the wall till June 5, 
when she left for manoeuvres. Her later movements correspond with 
those of the " Bulwark." 

Incuience of Cases. — Very few cases are recorded this year. One 
man developed the disease while resident in hospital on January 7. 
A midshipman was sent to hospital on January 19 for what was at the 
time diagnosed influenza, but as he showed a doubtful reaction and 
later developed Mediterranean Fever it is probable that this illness 
was the first manifestation of that disease. An E. B. artificer who 
was sent to hospital on April 10 for removal of tonsils developed 
suspicious symptoms nine days later, and once reacted in a dilution of 
1 in 50, but this was the only positive result in numerous examina- 
tions, nor could the organism be recovered from his blood or urine. 
This case has not been included in the returns. A fourth man, an 
ordinary seaman, developed the disease on April 18 ; he had been in 
hospital till March 27, and just before discharge showed suspicious 
symptoms, but gave no reaction. The disease was probably con- 
tracted there. Since then the only case that has occurred was 
another ordinary seaman who first felt ill on June 29, 24 days after 
leaving Malta. Very little information is available about this case. 

H.MJS, ^^ Formidable " — This ship provided no case throughout the 
year. She belongs to the same class as the others and recommissioned 
on October 1, 1904, her complement averaging about 740 men. 
Since commissioning she has only had about seven cases, although in 
1905 she was in dock or alongside for a period of 124 days. Her last 



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86 Major McCuUoch, Major Weir, and StaflP-Surgeon Clayton. 

case oocurred in December, 1905, and she remained on the station till 
August 13, 1906. It is interesting to note that her medical officer is 
inclined to ascribe this immunity to the practice of rarely sending 
a case to hospital except for invaliding. He further stated that tinned 
milk only has been used in the sick bay, and that mosquitoes were 
rarely seen. 

n.M,S, ^^Qtieen" — This battleship went home to recommission in 
April, and since her return has not provided a single definite case,, 
although one officer sent to Gibraltar Hospital was so diagnosed, but 
only on clinical grounds. Before her return to England four cases had 
occurred, of whom two had previously been in hospital. 

KM,S. " Prince of /rate."— This ship also left the station in May 
to recommission, and remained there till well on in the year. She 
has not provided any cases since her return, but before going had had 
two, one of whom had been recently in hospital, while the other was 
contracted while resident there. . 

Cruisers. — There are four first class and three second class cruisersr 
on the station, all the latter being sister ships. The first class cruisera 
are all recently built and well up-to-date in equipment, but the 
" Leviathan," which is much the largest of the four, carries more men 
than any ship on the station and suffers much more from over- 
crowding and defective ventilation. Ships of this class nearly always 
have a heavy sick list, while wounds are apt to become septic, and 
there is much sore throat. 

The accommodation in the " Lancaster," " Suffolk," and " Carnarvon," 
is much superior, and the latter, which is larger than the other two, is 
fitted with a bakery and the most up-to-date arrangements for 
cooking. The three second class ships are also very comfortable, and 
the accommodation is on the whole good, and ventilation, owing to 
their smaller size, is more satisfactory. They are employed on the 
outlying parts of the station and are comparatively rarely at Malta. 
The latrines in all these ships are on the upper deck, and in all there 
is a w.c. opening directly out of the sick bay, into which most of the 
excreta from the sick are discharged. 

3Iilk Supply, — Fresh milk has been used for officers in all these ships 
except the " Suffolk," the ward room officers of which ship, I believe, 
voluntarily gave up the use of it shortly after arrival in April. It has 
also been made use of in the sick bay in all but the " Suffolk " and 
"Venus." In one of these ships at the end of May it was found 
unboiled, despite orders to the contrary. 

Disinfection. — There have been no cases in the " Suffolk " and 
" Lancaster " since recommissioning, and no information is therefore 
available on this point. In the ** Venus " during her last commission^ 
besides the ordinary measures relating to excreta, clothing, etc., after 
the occurrence of a case of Mediterranean Fever, the fixtures in th 



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JEpidmniological Work in 1906. 87 

dck bay were removed, the plaoe scrubbed with perchloride of 
mercury lotion and then repainted. In the "Carnarvon," "Diana," 
and " Minerva," excreta, clothing, and bedding were disinfected, but 
in the "Leviathan" only the excreta. 

Hawkers of food stuffs were only permitted in the " Leviathan," 
which has contributed practically no cases. 

H,M,S. " LeviatJum" — This, the flagship of the cruiser squadron, has 
an average com^dement of 908, and has been on the station since 
December 12, 1905. 

Movements, — She was in Malta until February 10, being alongside 
the dockyard until January 22. She accompanied the fleet on 
February 10 and returned to Malta again, on April 20, till April 30- 
On May 5 she merely returned in order to proceed to Phalerum Bay. 
On her way back from the latter place she called at Port Said and 
Alexandria, and only arrived in Malta on May 28, leaving again on 
June 4. She was one of the four ships that came in again on 
July 28, and she sailed for the Adriatic cruise on August 3, not 
returning again till September 30. 

Incidence of Cases, — With the exception of one Maltese domestic 
who had a relapse on December 18, 1905, the only cases have been 
two which occurred in March in men who had been in hospital and 
were waiting in the "Egmont," one stoker who first felt ill on 
April 24, and a ward-room officer who noticed his first symptoms 
on June 19. There was no possibility of connection between any of 
these. 

H,M.S, " Carnarvon^* — This ship has a complement of 636 and has 
been on the station since June, 1905. She was in Sliema harbour in 
dockyard hands until February 10, and then proceeded on the Lagos 
cruise and afterwards by herself to Marseilles and Greece, not 
returning to Malta till May 3, and then only stopping two days before 
leaving for Phalerum Bay. She came back again on May 25 and 
went into dock from June 1 \x> June 5, leaving on that date for 
manoeuvres. She also returned on July 28 and remained till 
August 4, her subsequent movements corresponding with those of the 
" Leviathan." This ship was, therefore, almost altogether absent from 
Malta between February 10 and October 1. 

Incidence of Cases, — Three cases occurred in February, one on the 
10th and two on the 20th; all had recently been in hospital. A 
relapse case occurred in one of her Maltese on February 25, and on 
March 15 a stoker who had been discharged from hospital on 
February 9, after an attack of gonorrhoea, also first felt ill. These 
were all the cases that occurred during her first absence from Malta, 
but after the short stay she made in June, one case felt ill on the 21st, 
16 days after leaving, and a second on July 11, or a little over a 
month. A third case was put on the list on July 15 with rheumatism^ 

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88 Major McCulloch, Major Weir, and StaflF-Surgeon Clayton. 

but was found to hare Mediterranean Fever after admiasion to Bighi 
on July 30. This man had been there previously from November 3 to 
January 31 with enteric, and since diacharge had already been on the 
list three times for periods of a few days with febrile attacks and 
rheumatism. The chances are therefore in favour of this attack 
having been originally contracted in hospital and of its having existed 
since March, at which time he had his first bout of sickness. One 
more case occurred in this ship on August 8, four days after leaving 
Malta, the patient being a gun-room officer. The attack was not 
a severe one. Of the total of eight, therefore, five were probably 
contracted in hospital and one was an officer. The sleeping and 
messing billets of the last cases were in entirely different parts of the 
ship and there was no reason to suspect any relation between them. 

H,M,S, " Lcmcasier " and " Suffolk:'— Boib. these ships have comple- 
ments of about 680 men, both recommissioned at about the end of 
March, and neither has contributed a single case since arrival on the 
station. They were practically always with the fleet, and have 
therefore been in Malta on three occasions for 10 days or so previous to 
October; 

H.M,S, " Venus" — This ship has a complement of about 419, and 
has been in commission since February 7, 1903. She left the station 
early in May to pay off*, and did not return till August 4. She has 
been largely employed in Cretan waters. She was in Malta from 
January 1 to 31, and up to the 24th was in dock. She then left for 
Crete and remained there till May 1, when she returned to Malta and 
a week later sailed for England to recommission. She came back to 
Malta on August 2 and remained till the 19th, when she proceeded to 
Port Said and was there imtil November. 

Incidence of Cases, — No case had occurred in this ship from July, 
1905, until after she had been in dock. Then a Marine private went 
on the list for three days on January 21 and again on March 27 for 
51 days ; a second Marine was put on the list on January 29 and was 
59 days under treatment. A third Marine first complained on 
February 12, and a fourth on April 6, and finally an able seaman was 
admitted to Haslar on May 17. At first sight, therefore, this would 
appear to give an excellent illustration of the effects of docking, but 
a more detailed examination does not bear this out. First, the 
Marines were at Ghain Tuffieh rifle range from January 1 1 to 27, or 
rather more than half the time the ship was in dock, and, as a matter 
of fact, the first case was sent in from there, and the second went sick 
two days after retiuning. The third case had been in Bighi from 
October 10 to November 13, 1905, with what was returned as 
fimctional heart disease, but as he gave a doubtful reaction during this 
stay, and the course of the case rather suggested Mediterranean 
Fever, this may have been the first manifestation of that disease. 



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Epidemiological fFoi'k in 1906. 89 

This man was a ward-room servant and had drunk milk, probably 
unsterilised, on board. The able seaman was in hospital for the whole 
of January and was therefore not at all exposed to the possibility of 
infection in dock. This effectually disposes of docking aa a factor in 
the causation of this group of cases. 

The rifle range at Ghain TuflSeh is so isolated that the presence of 
infected mosquitoes is most improbable, and in fact mosquitoes are said 
iy the officer in charge to be practically non-existent there. The 
possibility of contact infection from the third case, who may have 
been the subject of the disease all the time, cannot be altogether 
ignored, but, unfortunately, neither of die first two cases were seen, 
and no information could be obtained with regard to their relation to 
him. 

Since the ship recommissioned there has been only one case, an 
officer who was discharged to the "Egmont " on August 18 to await 
passage home, and left on August 26 in the s.s. "Formosa." He 
•complained of illness the day before leaving and died in the Seamen's 
Hospital, at Greenwich, on September 26, of Mediterranean Fever. 

H,M.S. " Minerva J' — This ship commissioned in June, 1904; she 
has an average complement of ^bout 420. She was in Egyptian 
waters for the first five months of the year and only arrived in Malta 
on June 1. She went into No. 3 Dock from June 8 to 15, leaving on 
the latter date for manoeuvres. Mosquitoes were much complained of 
while in dock. She again arrived in Malta on July 24 and on the 
30th went alongside the dockyard for some days. On August 20 she 
sailed for home to pay off. 

This ship will be seen to have a larger proportion of infected persons 
among her Maltese than any other examined, and she has also spent 
a good many days in Malta during the hot months. She has not, 
however, contributed a single case of Mediterranean Fever. 

H,M,S, ^^DiwMb'^ — This ship has an average complement of about 
400 and was commissioned on September 30, 1904. She was lying in 
Egjrptian ports and Akaba in the Red Sea all the first part of the year 
until May 22, when she sailed for Malta, arriving on June 1 and going 
into No. 4 Dock from June 6 to 15, when she also left for the Atlantic 
manoeuvres. Mosquitoes were more complained of in this ship than 
in the " Minerva.'^ She returned to Malta on July 24 and August 9 
for two short periods, of two and five days respectively, before the 
Adriatic cruise. Her last stay at Malta dated from September 14, and 
three days later she went alongside the dockyard until October 9, 
finally sailing for England to pay off on October 12. 

Three cases occurred on board in the latter half of last year, but 
the only one in the first half of the present year was the case which 
is given in detail on p. 246. The next case, the master-at-arms, began 
to feel ill about Jultr 19, or some 35 days after leaving Malta and 



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90 Major McCulloch, Major Weir, and Stafif-Surgeon Clayton. 

coming out of dock. He had been ashore at Gibraltar, but not 
elsewhere. A third case first complained on June 22, but this i» 
a doubtful one, as his blood gave no reaction after leaving the ship. 
A fourth case has been returned from Plymouth hospital as 
commencing on October 10, but no further details are available. 

Small Ships; — 

H,M,S. " Barham" — This ship, a third class cruiser, arrived on the 
station in May, 1906, to relieve the "Sentinel," and has not con- 
tributed any cases. 

H,M,S, ^^ Surprise J^ — This is the Commander-in-Chiefs yacht and 
has been out on the station for many years. She has a complement of 
107 men and was last recommissioned on February 21, 1905. 

Movements, — She was in dock or alongside from December 5, 1905, 
to January 19, 1906, but since that time has only been in Malta for 
very short periods, except from May 25 to June 14. Her next visit 
was from August 2 to 5. Owing to her small size she is moored close 
to the shore and her officers state that mosquitoes are nearly always 
troublesome on board. Her usual billet this year has been in 
Dockyard Creek close alongside Senglea, so that she is really in closer 
relation to the houses in that place than are ships in dock on the 
other side. 

Up to August 23 no case had occurred in the ship, although two of 
her men during the time she was in dock contracted the disease while 
in Bighi for other illness. On August 23 her engineer officer was 
taken ill, and on November 3 one of her lieutenants was sent to the 
" Maine " hospital ship. The latter officer, however, had been ill for 
some time and the onsest of his illness is returned from Haslar as 
July 21. No other cases have occurred, and although this is rather 
suggestive of a contact infection it is curious that officers should as 
usual be singled out for attack, since the nearness of the shore to the 
anchoring billet occupied by this ship when in Malta affects officers 
and men alike. 

H.M.S. " Vukan " and the Destroyers, — The " Vulcan " is now the 
parent ship of destroyers and has a complement of about 448 men ; 
the crews of the destroyers bring the total to about 1180. She has 
been 12 years on the station, but was recommissioned in March, 1905. 
Her sick bay accommodation has not only to be used for her own men, 
but also for the crews of her satellite destroyers and in consequence is 
entirely inadequate, so that an extra sick bay has constantly to be 
screened off on the main deck and any severe case is as soon as 
possible transferred to hospital. Her latrines are also entirely 
peculiar to herself, as they are on the main deck and not the upper 
deck, but are approached from the latter by a narrow and tortuous 
ladder, and, being also much sub-divided by partitions, are exceedingly 
badly ventilated, almost impossible to keep clean and dry, and 



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Epidemiological Work in 1906. 91 

abomiiiably malodorous. One would expect that if inoculation from 
infective excreta plays much part in the production of the disease 
among the barefooted seamen that it would find its best opportunity 
in this ship. The galleys too are close to the sick bay. 

MiUc Supply. — Fresh milk is supplied both for ofiicers and sick bay. 

Disinfedion. — This is not a routine measure in case of Mediterranean 
Fever. 

With the exception of the period between January 18 and 26, when 
she made a cruise to Gibraltar and back, this ship did not leave her 
moorings in Lazzaretto Creek until February 14. In this billet, where 
she lies surrounded by the destroyers, she is not very far from the 
beach, which is on the Lazzaretto side, a favourite breeding place for 
uicartomyia ZammilHi, On February 14 she went round to Grand 
Harbour, and on March 7 went into No. 4 Dock for five days. On 
April 6 she left for Corfu, but returned again on the 18th to the 
Lazzaretto Creek, where she remained until May 5. She then took part 
in the Phalerum Bay demonstration, once more returning on May 21 
and sailing again on June 5 with the fleet. She subsequently made 
a stay at Malta from August 25 to September 6 and returned for the 
winter on the 30th. She was therefore in Malta for the greater part 
of the first half of the year, and has been longer there than any other 
big ship. 

During the first four months of this year there was a constant 
succession of cases, no less than 14 occurring, but since April 22 na 
single case has occurred among piersons actually belonging to the ship 
herself. In the first of these cases the onset was December 24, the 
next January 18, then there was one on February 8, two on the 17th,. 
another two days later, and two more on February 20. The next man 
had his first symptoms of Mediterranean Fever on March 12, but this 
was contracted while in hospital, so that no cases really occurred in the 
ship in March, and the onset of the next was April 1, when two first 
felt ill. Two more had their first symptoms on April 10 and the last 
on the 22nd. It has already been stated that one of these 14 actually 
contracted the disease while in hospital, but even more interesting is 
the fact that every one of the others without exception had been in 
hospital for other diseases within the three months preceding onset, the 
interval being under a month in five cases, under two months in five, 
and under three months in the remaining three, while the diseases 
from which they suffered were either venereal or surgical in 1 1 out of 
the 13. It is a very suggestive fact that a ship which is constantly 
obliged to send patients to hospital and also frequently contributes 
cases of Mediterranean Fever should have had an unusually large 
number in the early part of the year, all of whom had l)een in hospital, 
and that since the certain sterilisation of hospital milk, should have 
totally ceased to contribute cases, notwithstanding a fairly lengthy 



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^92 Major McCulloch, Major Weir, and Staflf-Surgeon Clayton. 

; «tay in Malta. It points strongly not only to the hospital as the place 
of contraction, but to the milk as the vehicle of infection. 

That being so it is interesting to find that in this ship also there is 
quite a marked grouping among the cases. Thus Mess 17 shows two, 
and Mess 15 another, while three belonged to Mess 23, and two more 
who fell sick on the same day to Mess 25. The sleeping billets of all 
in whom information was obtainable were widely separated. 

Destroyers. — It is quite impossible to enter in any detail into the 
movements of destroyers except to say that as a rule the majority 
accompany the parent ship and that they are moored in Sliema 
Harbour close to her. A proportion of them are almost constantly 
in dock, under which circumstances a nucleus crew only is left on 
board and the remainder hulked in the ^* Cruiser " or turned over to 
another destroyer. Owing to the paucity of accommodation for the 
sick in the " Vulcan " they are usually sent to hospital when ill. 

Twenty cases have occurred among their crews during 1906, and of 
these four first felt ill in January, two in February, four in March, 
four in April, three in May, one in June, and one in August. The last 
case had been notified as giving a positive reaction in his ship during 
P3rrexia of about a week's duration in July, 1905, so that this was 
possibly a relapse. With four exceptions, including the case just 
mentioned, all had recently been in Bighi with other illness, but in 
two instances at a period more remote than three months. Of the 
remaining three who had not been in hospital, two were officers, and 
one of these was the June case and came from a destroyer which ¥ras 
alongside at the time. Just as with the "Vulcan," therefore, the 
occurrence of cases has greatly diminished coincidently with the 
certainty of sterilisation of milk in hospital. 

Two ships provided three cases each, and three two cases each, but 
these showed no evidence of any connection, and some of them were 
almost certainly contracted in hospital. 

Conclusions. — The period under consideration is too short, and the 
<jases too few, to justify any definite conclusions, but so far as it goes 
it may be held to suggest : 

(1) That defects in accommodation and ventilation and the 
prevalence of ailments resulting from these do not appear to exercise 
much influence. 

(2) That duration of stay on the station appears to be of more 
importance, but that there are constant exceptions. Judging from the 
histories of the " Implacable " and ** Irresistible,*' where a ship begins 
badly she tends to go on in the same way, and the converse is 
illustrated by the " Formidable." 

(3) With very few exceptions, cases go on the list within six weeks 
of leaving Malta, and ships which are much away do not provide cases 
until after their return as a rule. 



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Epidemiological Work in 1906. 95 

(4) Just as was found by Colonel Davies, there seems to be na 
relation between the completeness of the disinfection carried out and 
the occurrence of cases. 

(5) The grouping shown would be more suggestive of mosquito or 
contact infection if so many did not show a previous hospital history 
and if it related to sleeping billets as well as to messes. 

n. — ^Faots Eucited by the Study of Individual Cases. 

In addition to the information derived from cases personally investi- 
gated, a considerable amount was available from forms which had been 
distributed in the fleet in 1905, and sent to my predecessor, or Staff- 
Surgeon Shaw, on the occurrence of a suspected or developed case of 
Mediterranean Fever. 

Chiefly owing to differences in the speediness of diagnosis, these vary 
considerably in the completeness of the information recorded, and,, 
accordingly, to almost every question there has been a differing number 
of answers. 

The evidence in this part of the report is therefore derived from three 
sources — ^first, cases personally interviewed, 70 in number, including 
48 from the Service afloat, 9 from the hospital, 8 from the dockyard, 
and 5 Maltese; secondly, a certain amount of information collected 
about 13 cases not personally interviewed, which occurred in ships away 
from Malta and never retiu-ned there; and, third, the information 
obtained from the forms referred to above. Where there can be no 
doubt as to the accuracy and completeness of the evidence provided, 
these will be combined, but otherwise they will be treated separately. 

It is almost unnecessary to say that this part of the enquiry has been 
much interfered with by the continued absence of the fleet from Malta, 
and by the very gratifying decrease which has latterly taken place in 
the number of cases. 

For obvious reasons connected with the difference of environment,. 
these cases are considered under the following headings : — 

Service afloat, officers and men ; English civilians employed in the 
dockyard; Maltese, afloat and ashore; hospital residents. The facts 
with regard to these which have a bearing on hospital conditions have 
already been discussed at p. 74. For certain general considerations 
no such distinction is necessary, and these are therefore first dealt 
with. 

Time <m Station, — The shortest interval intervening between arrival 
in Malta and onset of symptoms recorded in these returns was 17 days. 
One case was probably only eight days, but no definite informa- 
tion is available. As will be seen from the next table, which, in 
addition to giving the duration of residence in the total number about 
which yif ormation was available on this point, also compares the interval 



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94 Major McCuUoch, Major Weir, and Staflf-Surgeon Clayton. 

in those arriving in the hot and cold weather respectively, such a short 
period is decidedly the exception : — 

Table XXVI. 



Time in months on station 


Under 8. 


8 to 6. ' 6 to 12. 

I 


12 to 24. 


Over 24. 
12 
12 


Those persons arriring from 
April to September 

Those persons arriying from 
October to March 

Total 


6 
2 


12 
12 


24 
25 


36 
83 


1 
8 i 24. 


49 


69 


24 


1 









- Except for the period under three months, there is no evidence here 
that persons who arrive in the hot weather are attacked any earlier 
than those arriving in the winter, a fact which, in view of the way in 
which new arrivals suffer from the attacks of mosquitoes, rather argues 
against a mosquito-borne infection. It must be noted, however, that 
ships are more often absent from Malta in the summer than the winter. 

Previous Service on Staiion, — Only 12 out of 52 persons who gave 
information on this point had previously served on the station. 

In Dock or alongside Dockyard. — Twenty out of 99 cases developed in 
ships which had been in dock or alongside the dockyard wall within 
the previous 30 days, but one of these 20 was sleeping in the 
" Egmont." As the whole question of docking is discussed at p. 63, 
no further remark will be made, except to note that 10 of these had 
recently been in hospital 

The Presence of Sore Throat and other conditions of the Movih which might 
conceivably piovide opportunities for Inoculation by Micrococcus melitensis. 
— Only 14 out of 52 cases in which the presence or absence of sore 
throat was enquired into admitted having any throat symptoms, 
and similarly of 56 cases in which the condition of the tonsils was 
examined to ascertain the presence of chronic enlargement only 14 
were found to be affected. The teeth were fairly good in 34, poor in 
six, and very bad in five. In answer to enquiries about smoking, all 
except five were found to smoke to a greater or less extent. The 
amount of evidence therefore suggesting possibilities of absorption 
from the mouth was not very great. 

Infection from Abrasiom produced on Urine-polluted Grownd whUeplaying 
games. — Although there does not seem to be a great probability of 
the recreation grounds in general use being much polluted in this way, 
the suggestion has been made that infection may thus occur, and the 
patients were therefore asked whether they had recently played in 



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Epidemiological Work in 1906. 95 

Malta any games in which abrasions might be produced. Five out of 
7 officers, but only 11 out of 44 men were found to have done so, and 
the probabilities are against this playing any part in the dissemination 
of the disease. 

Fads elicited wUh regard to eases occurring in the Service Afloat. — In 
dealing with the incidence of the disease among this section of the 
naval population, one of the most important questions to determine is 
that of the possibility of the contraction of infection on board the ship 
itself and the various ways, if any, in which this may take place. 
Where a ship is lying in the stream, the methods by which persons on 
board are likely to be infected may for practical purposes be summarised 
as: — 

(1) Infection by foodstuffs brought on board, and especially milk or 
its products. 

(2) Various forms of contact, direct or indirect, with pre-existing 
«ases, ambulatory or developed, occurring on board, and through the 
medium of biting flies with cases occurring ashore. 

(3) Infective dust. 

(4) Milk. 

As milk containing Micrococcus melitensis is known to be supplied at 
4;imes to ships, it seems by far the most probable vehicle of infection, 
which may occur as the result of ingestion, convection by flies to other 
food, or, possibly, in rare cases, by inoculation. The latter probability 
is not a great one as far as ships are concerned, since all officers' cooks 
are Maltese. 

With regard to the ingestion of milk in Malta, notes were obtained 
of 59 men belonging to the Service afloat, excluding cases among 
Maltese. Thirty-five of these, including six of the Sick Berth Staff at 
Bighi, already dealt with at p. 56, had had milk while in hospital, and 
one other, at least, while on the sick list. Two^more had taken it in 
«ome form elsewhere, and two had taken it, but not for a long time, 
one of these latter being an E.R. artificer from the *' Vulcan," who was 
reported in July, 1905, to have given a positive reaction on board 
during a week's pyrexia. At that time he had been drinking milk 
daily in his home at Sliema, but had taken none since. Seven more 
men, including two of the Sick Berth Staff at Bighi, only admitted to 
having milk with tea, and two others, not personally interviewed, were 
said to have probably had milk. No notes were obtained about three 
<»ses, and seven denied having ever taken milk. As, however, of these 
latter, two were found to have been in Bighi recently, one for rheu- 
matism, the other as a member of the staff, there is some reason for 
doubting the accuracy of this statement, which was not obtained per- 
sonally. Out of 59 men, therefore, seven had milk only in tea, 42 in 
various other forms, and seven had none. On the other hand, of 



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96 Major McCuUoch, Major Weir, and Staff-Surgeou Clayton. 

1 1 officers, one had taken milk in hospital within a month of his illness^ 
four more had had it elsewhere in various forms, and one was stated to 
have probably taken it. Three said they only took it in tea, but two 
of these had also had ice creams recently. About the two remaining 
cases, no facts were forthcoming on this point. Of the four who had 
certainly taken milk, one stated that he practically lived on it, but that 
it was always boiled by his Maltese servant in his house ashore, an 
assertion that there was unf ortimately no opportunity of testing, and a 
second had, some three months before coming on the sick list, been 
trying a diet consisting of hot and cold milk alternately to the extent 
of about six pints a day. In no case among the officers, therefore, was 
there any absolute denial of milk drinking. 

In the returns sent in to Staff-Surgeon Shaw the question asked was 
whether fresh goats' milk had been taken during the preceding 
30 days. The following figures were obtained from the tabulation 
of these returns, cases contracted while in hospital, the Sick Berth 
Staff, and Maltese being omitted from t^e consideration : — 

Among 40 patients who had recently been resident in Bighi for 
other illness, 38 had either had no milk since discharge, or where the 
interval before onset was over 30 days, for that period. Two gave 
a history of milk drinking, but one only in tea. The question of milk 
in hospital was in the majority of cases ignored, but has already been 
dealt with at p. 71. 

Of 34 patients who gave no history of previous hospital residence 
seven, including three officers, had taken milk, but one only in tea, and 
a second had obtained the milk at Corfu. 

Canvedion by Flies, — Since galleys and latrines are places where flies 
habitually congregate, and since infective material in the shape of milk 
is sometimes present in officers' galleys, and in the shape of urine in 
the latrines, especially that in the sick bay, a suggestion of the 
possibility of the conveyance of infective material in this way to food 
in messes near these special parts of the ship is not altogether 
unreasonable. 

The relation of the affected messes to them has therefore been noted. 
In seven cases the mess was close to the officers' galley, and in four 
more to the ship's galley, three of the latter occurring in one group in 
the "Bulwark," as stated on p. 79. The group of cases in the 
'* Irresistible," described at p. 84, belonged to messes not far from the 
sick bay and close also to the ship's head. The sick bay attendant 
in this ship and the sick bay steward in the "Implacable," both 
of whom messed and slept in the sick bay, also contracted the disease, 
but in their case the possibilities are, of course, more various. Out 
of the total of 70, therefore, 18 were in relation to these parts of the 
ship. 

Other Forms of Food, — The sources of food, both that supplied by the 



Digitized by VjOOQ IC 



Epidemiological Work in 1906. 97 

Service and by the canteen and messes, were investigated, but the 
only form, other than milk or its products, upon which suspicion can 
rest is to be found in raw fruits and vegetables. Of the 57 persons 
interviewed, however, seven stated that they never took either fresh 
v^etables or fruit, and in the majority of cases who were in the 
habit of taking the latter, skinned fruits, such as oranges, were the 
usual form. 

Qoat Cheese, — Only in the case of one man could a history be 
obtained of the ingestion of goat cheese, and it was not made use of 
in any ship in which enquiry was made. It may be regarded, there- 
fore, as quite an exceptional article of diet. Butter is practically 
always tinned. 

The Question of Hawkers, — The selling of food stufife^or drinks on 
board was only permitted in two sea-going ships, and neither of these 
had many cases of Mediterranean Fever. Milk was sold by hawkers 
in the " Egmont." As it was found, however, that ice creams were 
being sold to the men in one ship at least, a recommendation was made 
with regard to this, with the result stated at p. 73. 

Mosquitoes, — With a ship Ijdng out in the stream, biting flies might 
presiunably be infected ashore, and either fly ofF where the ship 
was near the beach or be conveyed in boats with fruit or some- 
thing similar. On the other hand, the possibility of their carrjdng 
infection from case to case on board must be admitted, but with 
prevailing conditions on a lower deck crowded with disturbing 
elements and subject to repeated cleansing a long stay by a mosquito 
in any particular part is decidedly improbable. As, however, such 
a method of dissemination has been suggested, it was desirable to note 
relationships to pre-existing cases and to possible reservoirs of infection 
in the shape of Maltese on board. 

The grouping in three ships, which has already been discussed, 
refers to messes during the day, and not to sleeping billets, which in 
the majority were far apart. Since during the day the bluejacket is 
pretty constantly occupied away from his mess, such a grouping is, 
therefore, far more suggestive of something connected with food 
supply than of mosquito infection. 

Out of the 70 cases 12, including two belonging to the Sick Bay 
Staff of ships, were found to have been in the near neighbourhood of 
pre-existing cases, usually in the same or adjoining mess. Eight more, 
while recently in hospital for other illness, had been in the same ward 
and in neighbouring beds to cases developing there. In the old 
returns contact was noted only in five cases out of 60, four of these 
referring to contact while in hospital. Of the personally investigated 
cases five more had been in near relation to Maltese on board who 
may have been suffering from ambulatory attacks. Two are especially 
suggestive, the first having two Maltese sleeping on the deck below 
(2089) h 



Digitized by VjOOQ IC 



98 Major McCulloch, Major Weir, and Stafif-Surgeon Clayton. 

his hammock, and also having worked just before his illness with the 
dockyardsmen carried by the ship, of whom two were found to react, 
while the second was working on board his destroyer with several 
dockyard men. 

With regard to direct evidence about mosquito bites, seven persons 
said that they were very rarely bitten, 18 occasionally, 10 frequently. 
Three more did not remember being bitten, but their messmates had 
recently complained, and 19 had neither been bitten nor heard com- 
plaints. A good many of the persons who admitted to having been 
attacked stated that they had been much bitten on first arrival on the 
station, but not so much latterly. 

Taking all this evidence for what it is worth it cannot be regarded 
as pointing very strongly to direct contact infection or as greatly 
incriminating mosquitoes. 

Indirect Contact. — Infected clothing or bedding. Only one man out 
of over 150 who were asked the question was found to have ever used 
any but his own hammock, and even in this case it is quite improbable 
that this had been used by a pre-existing case. This possibility may, 
therefore, be disregarded. With the exception of the Sick Berth Staff, 
too, practically no histories were obtained of contact with the effects 
of patients suffering from the disease. A very few had taken part in 
transferring patients to the Mediterranean Block while in hospital, or 
in taking bedding to the disinfector, one or two had collected the 
clothing of messmates on board, but the number of histories of the 
sort is so insignificant that it is hardly worth recording, and the 
amount of risk run in such cases was practically nil as compared with 
those constantly incurred by the Sick Berth Staff in hospital. 

Inoculation from Infective Excreta in Double Bottoms and other Parts of 
the Ship. — The habits of the Maltese labourers working on board have 
already been referred to at p. 65, and this affords, therefore, quite 
a reasonable possibility. Information on this point was obtained in 
169 cases, of whom nine had, just previous to the onset of illness, been 
working in bilges, seven in double bottoms, while 153 had not been 
engaged in any work of the sort. 

Inoculation from Infective Urine on the Floor of Ship's Heads or the Dock- 
yard Latrines. — In only one case of the 169 was the person attacked 
working in heads or latrines, so that the evidence is against this 
method of transmission. A very similar possibility, however, exists in 
the practice of going to the ship's head barefoot, especially in view 
of the prevalence of sea cuts and other aids to inoculation. The very 
general distribution of cases and the special liability of officers argues 
against this pla3ring a very important part, but the question was asked 
in 24 cases, 12 of whom stated that they always wore some form of 
foot covering, five occasionally went to the head without and seven 
frequently did so. 



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Epidemiological Work in 1906. 



99 



Examination of Contads, Previous Cases, amd the Maltese in Ships, — In a 
ship, as opposed to a house or barrack room, it was obviously waste of 
time to attempt to examine contacts, and this has accordingly only 
been done in a few cases occurring ashore. The 13 men composing 
the hospital guard were examined on the occurrence of a case among 
them, and the husband and daughter of Mrs. T. (see p. 106), who had 
been ill some six weeks before she was, were also examined, but in 
every case the reaction was negative. 

The Maltese on Board Ship. — It had been intended to examine for the 
presence or absence of agglutination reaction all the permanent 
Maltese in the fleet, and to plate out the urine of those who gave 
a good reaction. This project was, however, greatly interfered with 
by the continual absences of the fleet, and in the second place, owing 
to the constant pressure of other work in the laboratory, one did not 
feel justified in asking for much work of this sort to be done. 
Surgeon Hunt of the " Suffolk " very kindly examined the men in his 
ship, while away on a cruise, and sent those reacting to the laboratory 
for verification. 

The following table represents the results so far as the examination 
extended : — 

Table XXVII. 



Ship. 



"London" ... 
"Implacable" 

"Diana" 

"Minerva" ... 

"Ipresistible" 
"Suffolk" ... 

Total ... 



Number of 

Maltese 

examined. 



28 

29 
13 
18 

27 

20 



185 



Number 
reacting. 



Urine 
examined. 



' Number of 
cases of 
I Mediterranean 
FeTerinyear. 



1 up to Vs + 

1 » V& + 



Titj + ; Once. Nil 
i 
^5 + , Twice. Nil 

I 



12 



Nil 



18 

14 

4 

Nii 

14 

Nil this 
commission 



The history of these cases was enquired into in several instances. 

The one man in the " London " stated that he had never had any 
fever, while the one in the " Implacable " was 78 days under treat- 
ment in Bighi at the beginning of the year with Mediterranean Fever. 
(2089) h 2 



Digitized by VjOOQIC 



100 Major McCulloch, Major Weir, and Stafif-Surgeon Clayton. 

The cases in the " Minerva " were carefully enquired into by Surgeon 
Eichardson, and of the three who gave a good reaction, one stated that 
he had never been ill ; another, that he had only been laid up for 
about a fortnight three years previously with what was said to be a 
cold, while the third had had Mediterranean Fever five years before. 

The urine was also plated out in three ambulatory cases, two in 
hospital, and one belonging to the " Diana," and in two previous cases 
occurring in the " Implacable," and one in the " Carnarvon," but no 
Micrococcus melUensis was ever isolated. 

The blood of 48 out of the 53 dockyardsmen who at various times in 
the early part of the year were embarked in different ships for the 
purpose of fitting fire control were also examined. Two gave a 
+ reaction in 1 in 10 and 1 in 20 dilution, two only in 1 in 10, and 
two more gave a doubtful reaction in 1 in 10. 

This investigation, so far as it goes, would appear to indicate, that, 
as might be expected, latent infection exists among the Maltese in 
ships, but would not suggest that it plays any part in the dissemination 
of the disease. In the Table above it will be noted that the ships 
which suffered least had the largest proportion of Maltese giving a 
positive reaction. 

Evidence tvithrega/rd to the Possibilities of Exposure to Infection Ashore. — 
Men. — Of the 59 men whose cases were personally investigated, nine 
were living in Bighi Hospital, and 29 more had recently been there as 
patients, eight within a month, 1 1 within two months, and seven within 
three, the rest over that time. Since the discharge from hospital of 
these 29, 12 had been ashore in Malta once or twice, seven occasionally, 
two frequently, while seven had not left the ship. One more had not 
been ashore in Malta, but occasionally in other places. Similarly, 14 
had occasionally (in the majority of instances once or twice) slept ashore 
since discharge from hospital, and 13 had not done so at all. No infor- 
mation on this point was available about two. 

Of the 21 men who had not been resident in hospital, two were once 
or twice ashore in Malta in the six weeks or more preceding the onset 
of illness, eight occasionally, three frequently, and two were living 
ashore, but one of them for only about a week at the range. Three 
others were occasionally ashore elsewhere, but not at Malta, and three 
were never ashore at all. The figures with regard to sleeping very 
closely correspond to the others : seven slept ashore occasionally, three 
frequently, and 1 1 had not done so at all. 

Officers. — Only one out of the 11 had been previously in hospital, 
and in the interval between discharge and onset he was living ashore. 
Of the remainder, one^ was ashore in Malta once or twice, two 
occasionally, three frequently, and the remainder, with the exception 
of one whose destroyer was alongside the dockyard, were living ashore. 
Only these latter, four in number, had slept ashore at all lately. 



Digitized by VjOOQ IC 



Epidemiological Work in 1906. 



101 



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Digitized by VjOOQ IC 



102 Major McCuUoch, Major Weir, and Staff-Surgeon Clayton. 

The evidence derived from the forms sent in to Staff-Surgeon Shaw 
relates in the large majority of instances to the movements of patients 
in the 30 days preceding onset, since that is the form in which the 
question was put ; but in a few, who had recently been in hospital, 
information is given with regard to the period since discharge. 
Omitting cases contracted while resident in hospital, and those 
occurring among the Sick Berth Staff there, and also the Maltese and 
dockyardsmen, information is available on this point in 93 cases, of 
whom one officer and 55 men had recently been in hospital, and in 35 
of these their movements for the entire interval between discharge and 
onset are recorded. The results are perhaps best put in tabular form 
(see Table XXVIII, p. 101). 

So far as it goes, therefore, this information — which may be accepted 
as pretty accurate, since in the large majority of cases it has been 
verified by examination of leave books — agrees essentially with 
what has already been stated. Officers, for instance, are seen to go 
ashore more than the men in the daytime, but, in the case of those 
serving afloat, to sleep ashore much less frequently. It follows, there- 
fore, that this suggests some cause operating in the daytime to account 
for the increased liability among them. 

It shows also that the majority of the cases developing after treat- 
ment in hospital for other illness have been comparatively little exposed 
to the chance of infection ashore, and that the possibilities of this 
having occurred during the interval after discharge from hospital are 
therefore correspondingly lessened. 

Facts Pointing to the Contraction of the Disease in Malta rather than 
elsewhere, — Evidence with regard to the period intervening between 
departure from Malta and onset of symptoms has been collected in 
60 cases which occurred during absence from Malta, and the following 
table gives the result : — 

Table XXIX. — Showing Interval between Departure from Malta and 
Onset of Symptoms in Cases occurring elsewhere. 



Within 
Iweek. 


2wk8. 


3wks. 


4wk8. 


5wk8. 


6wk8. 


7 wks. 


15 11 


11 


8 


5 


4 


1 



8 wks. 



Over 
8 wka. 



The enormous majority are seen to occur within a month of 
departure, and further evidence is afforded by the diminution which 
inevitably follows the departure of the fleet during the summer, and 
which during the past two years has been accentuated by the increasing 
length and frequency of the cruises. 



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Epidemiological Work in 1906. 103 

Dockyard, Civilian, E n gl ish. — A group of cases of Mediterranean 
Fever occurring among dockyard officials and their families in Sliema. 

Incidence of Cases, — The earliest case occurred in the person of 
Mr. J. J., draughtsman in the dockyard, who lived in a flat situated in 
one of three houses (House B) belonging to a. boarding establishment 
in Sliema. He had only b^en in Malta three and a half months and 
first felt ill on April 12. Almost at the same time, about April 16, 
two out of four children in the family of another dockyard official, 
living some 400 yards or more further down the same street (House A), 
also complained of illness and one gave a positive reaction, the other 
being only ill for a week and her blood not being tested. On April 27 
a third child in the same family became ill, and presented a positive 
reaction. The fourth and only other child was an infant 10 months 
old. On going into the history of this second family it was found that 
until two months previously they had lived in the same house as the 
first case and, in fact, had for some time been fellow lodgers, but had 
seen little of one another since leaving. This family had been two and 
a-half years in Malta and had always used milk unboiled, the children 
chiefly with porridge. The mother also used the milk, but previously 
they had none of them suflered from illness. The milk was obtained 
from the same goat-herd as in the house where the first case occurred. 
On May 11 Mr. E. H., living in the same boarding establishment as 
Mr. J. J., but in the third house (House D), that is to say, the house 
at the opposite end of the establishment of three, had a febrile attack 
and symptoms suggesting Mediterranean Fever, but gave no reaction. 
When seen on June 19, however, a tube of blood was obtained and 
when tested was found to react up to 1 in 200, although he had 
returned to duty on May 21 and was apparently well. On May 21 
Mr. T. C, draughtsman, living in the same house, was attacked by pain 
in the foot and fever which lasted till the 28th, and on June 8 was 
placed on the list with what proved to be a severe attack of 
Mediterranean Fever. 

All the houses are situated on the sea front and accordingly in close 
relation to the very nimierous breeding places of Acartomyia which are 
to be found on the rocks at Sliema, while the street is also much 
exposed to wind, and consequently to dust. The houses are com- 
paratively recently built and the sanitary arrangements were in all 
cases modem in design and in good order. 

The boarding establishment in which Messrs. J. J., E. H., and T. C. 
lived consisted, as has been stated, of three houses (B, C, and D), two 
of which (C and D) were in communication and served as a sort of 
mess, while the other (B) was let in flats. This latter house had been 
given up at the time the second case occurred. They were adminis- 
tered and supervised by the same stafl*, and the milk supply was the 
same for all. None of the five Maltese servants gave any history of 
recent illness. 



Digitized by VjOOQ IC 



104 Major McCuUoch, Major Weir, and StaflT-Surgeon Clayton. 

That part of the establishment used as a mess accommodated nine 
dockyard oflScers, four of whom lived in the middle house (House C) 
(none of whom were attacked), while five lived in the end house (D) 
and two of them suffered. Among them, Mr. T. C. had been the 
shortest time in Malta (nine months), while Mr. E. H. had been two 
years in the island. All except one had been in the habit of taking 
fresh goats' milk with porridge and also in tea ; the one exception took 
it in tea only. He has not suffered from Mediterranean Fever. 
Mr. J. J., the first case, who had lived in the other house (B) in a flat 
with his wife, also took it with porridge. 

All but two of the nine used mosquito nets, and all agreed in saying 
that mosquitoes had not been troublesome this year, but that last year 
they were a great nuisance in the dockyard. The two who used no 
curtains were neither of them attacked ; one of them lived in the centre 
house of the three (C) where no case occurred, and the other in the 
same house (D) as the last two patients. Mr. J. J. also used a 
mosquito curtain and stated that he was extremely particular about it, 
examining it each night with a candle before retiring. Mr. T. G. 
appears to have been in the habit of doing much the same. 

Previous Cases in House, — Two cases had occurred in August and 
September, 1905, both of whom lived in house (D). In addition, 
another of the mess had been attacked after arrival in England on leave 
about August, 1904, but at this time, although the establishment was 
the same, the house was an entirely different one and in a street further 
from the sea. 

MUk Supply. — ^The same goat-herd had supplied the establishment 
for a long time and was in addition the usual source of supply for the 
family in which the three children were attacked, but in contra- 
distinction to the latter who drank the milk unsterilised the proprietress 
assured me that the milk was always scalded before use and was most 
emphatic in her expressions of confidence in the reliability of her 
Maltese servants on some doubt as to this being suggested. On the 
occurrence of the second case (Mr. T. C), however, the house was 
again visited, and some milk standing by his bedside was tested and 
found to give the characteristic reaction with the ortol test. A further 
sample was then requested and was brought up by one of the servantfl 
who, on seeing the test about to be applied, volunteered the information 
that it had not yet been scalded. As the hour at which the milk was 
delivered was said to be 5.30 a.m., and it was then nearly noon, one 
may be pardoned for expressing doubts as to whether the confidence 
reposed in her domestics by the mistress of the house was not misplaced. 
A sample of this milk was sent to the laboratory, but was too con- 
taminated for examination. 

Samples were afterwards obtained from 20 of the animals belonging 
to this goat-herd and one was found on repeated examination to give a 



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Ejridemiological Work m 1906. 



105 



very marked reaction and was frequently plated out in the Public Health 
Department, but Micrococcus meliiensis was never isolated. This herd is 
dealt with in Dr. Critien's report, and on comparison with him it was 
found that he received notifications of three cases from a house 
{House E) in a street quite a quarter of a mile away, but supplied by 
the same milkman. The dates of onset in these three were April 20 
and 24 and June 15 respectively. 

Among the persons, therefore, supplied by this herd, which included 
at least one infected animal, no less than eight undoubted and one 
possible case of Mediterranean Fever occurred within a comparatively 
short space of time. These were located in four different houses, in 
three instances widely separated from one another, while no such 
correspondence was to be found between them in conditions suggesting 
other methods of infection. 

The following table recapitulates the dates of onset : — 

Table XXX. 



Name. 


Sex. 


Date of onset. 


House. 


Remarks. 


Mr. J. J. 


M. 


AprU12 


B 




C.J. 


M. 


„ 16 


A 




C.J. 


F. 


» 16 


A 


Only a week ill. No exami- 
nation for reaction 


Mr. S. 


M. 


„ 20 


E 


Dr. Critien's report 


Mr. (*. 


M. 


„ 24 


E 


it a 


F.J. 


F. 


,. 27 


A 




Mr. E. H. 


M. 


May 11 


D 


Onl^ a week ill, but reacted in 
dilutions up to 1 in 200 


Mr. T. C. 


M. 


» 21 


D 




Mr. O'R. 

1 


M. 


June 15 


E 


Dr. Critien*B report 



It may be mentioned that Messrs. J. J., E. H.,and T. C. all worked 
in the dockyard, in the same block of buildings, and stated that last year 
they were much troubled there by the attacks of what was evidently from 
the description Stegomyia fasdata. All, however, agreed in stating that 
up to the time of illness this year none had been seen, which is quite 
in accordance with what might be anticipated at the time of year. At 
all events, the prevalence of mosquitoes in the dockyard would throw 
no light on the remaining cases and the probabilities would seem to be 
enormously in favoiu* of milk as the vehicle of infection in this series 
of patients. 

Isolated Cases among English Civilia/n Dockyard Employees, — In addition 
to the group of cases just discussed, three isolated cases were personally 
investigated. 

Environmental Conditions, — One man, S. B., an engine fitter, lived in 
Vittoriosa ; a second, E. W., and the third case, a female, Mrs. T., 



Digitized by VjOOQ IC 



106 Major McCulloch, Major Weir, and StaflT-Surgeon Clayton. 

the wife of a dockyard employee, lived in diflFerent parts of Senglea. 
In all three cases the house was situated 'in dirty crowded localities, 
infested by goats and other animals, and in all three the sanitary 
arrangements were of the peculiar Maltese type described by 
Johnstone, and left much to be desired. By far the most objection- 
able in this respect was that of Mrs. T., where there was a hand- 
flushed closet pan in the small room where cooking was carried on, 
an open communication with the drain just outside the window, 
and another hand-flushed closet just outside her bedroom door. With 
regard to the sanitary condition of surroundings, therefore, these few 
cases are seen to aflbrd a most notable contrast to the conditions under 
which most cases in the Service afloat are contracted. 

Milk History, — S. B. had been in hospital in January, 1906, for some 
considerable time with rheumatic symptoms and a slight urethral dis- 
charge. On February 2nd, but never again, his blood had given a 
positive reaction in a dilution of 1 in 50. During this stay he had had 
milk, and he had also been in the habit of drinking it by itself in his 
own home ; but in his present lodgings, which he had occupied since 
discharge from hospital, it was said to be tinned. The symptoms of 
his definite attack of Mediterranean Fever began early in June, but 
the probabilities are rather in favour of his first stay being also due to 
this cause. 

In both the other cases a milk history was easily established, E. W. 
taking it in egg flips and Mrs. T. with fruit. In both cases the milk 
was obtained in the usual way from casual goat-herds at the door. 

Contact, — In the case of the two men there had been no recent illness 
of any sort in the house, but the husband and one daughter of Mrs. T., 
both of whom had taken milk, had, some six weeks previously, suffered 
from pyrexia. In both, however, the agglutination reaction was 
negative. 

Mosquitoes. — S. B. stated that these had troubled him in the house 
he had occupied before going to hospital the first time, but not in this 
one. E. W., whose symptoms were first noticed about the middle of 
September, had been much attacked in the boiler shop in the dockyard 
by a striped mosquito, evidently Stegomyia, and by a smaller variety in 
his house, but Mrs. T. had not noticed any. Neither of these three 
persons used nets, and the probabilities are that mosquitoes were 
numerous in all three houses. 

Maltese. — The Maltese personally interviewed included four 
serving in ships, and one policeman in the dockyard. All, however, 
slept ashore while at Malta. Owing to linguistic and other difficulties, 
information had been hard to obtain in these cases and is not 
altogether reliable, more particularly with regard to previous history, 
contact with other cases, and facts relating to mosquitoes. 

The details may be summarised as follows : — 



Digitized by VjOOQ IC 



Epidemiological Work in 1906. 107 

All lived in entirely different parts of Malta, including Cospicua, 
Casal Paula, Zabbar, Misida, and Senglea, and all belonged to different 
ships. Three gave histories of similar illness previously, two nine 
years before, and the third in 1905, but neither had been in hospital. 
Four occurred while at Malta, the last a fortnight after leaving. 

Contad and Mosquitoes. — No history of any contact with pre-existing 
cases could be obtained. One man said he was never troubled by 
mosquitoes, a second was occasionally bitten, a third that they were 
numerous in his house, but that he used a sheet as a protection. No 
information could be obtained from the other two on this point. 

Milk History, — Two drank milk freely by itself, a third took it with 
porridge and fruit, and occasionally by itself on board his ship (he was 
a gunroom domestic), the fourth took it only in tea except when ill, 
and the remaining man denied taking it at all, but his knowledge of 
English was so limited that the information in this case is by no means 
reliable. Four cases were reported on the old forms, and of these two 
drank milk ; about one man it is stated that he did not drink it on 
board, and as to the fourth there is no information whatever on this 
point. 

The evidence to be derived from these few odd dockyard cases and 
Maltese is entirely inconclusive, but on the whole it is not incompatible 
with milk infection. 

m. A MORE COMPLETE HISTORY OF THE OUTBREAK OF 
MEDITERRANEAN FEVER ON BOARD THE S.S. " JOSHUA 
NICHOLSON." 

The original account of this outbreak of Mediterranean Fever on 
board the "Joshua Nicholson" was given in the correspondence 
column of the * Journal of the Royal Army Medical Corps' for 
January, 1906, in the following letters from Dr. M. Armand Ruffer, 
Captain Kennedy, R.A.M.C., Malta, and Dr. Gotschlich, Director of 
Sanitary Services at Alexandria, respectively, and in an editorial in 
February, 1906:— 

Dear Bruce, — I have just seen Dr. Gotschlich, who told me of a 
ship starting from Malta with a number of milch goats for London. 
The captain, officers, and a certain number of the crew drank the milk, 
and nearly all those that did so contracted Malta Fever, whereas the 
others did not. I have urged Dr. Gotschlich to publish pjirticulars at 
once. 

Yours sincerely, 

M. Armand Ruffer. 

Dear Colonel Bruce, — I came across a very interesting thing in 
connection with the infection of Mediterranean Fever by means of 
goats' milk. I got to hear from Dr. Stilon, who is writing for fuller 



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108 Major McCuUoch, Major Weir, and Staff-Surgeon Clayton. 

particulars, of a ship trading between Antwerp and Egypt, which called 
in here the other evening, and the captain of which and another man 
came ashore to consult Dr. Stilon, who found them suffering from 
symptoms of Mediterranean Fever. He took samples of their blood, 
which he sent to the laboratory. Dr. Micallef did the reactions, and I 
only saw them after he had put them up, when there was an undoubted 
reaction. He had no more blood for me to test. 

These two men left Malta on board their ship early next morning, 
and I did not hear of the case for 24 hours after, but particulars of 
which, as far as I can gather from Dr. Stilon, are as follows : — 

Two months ago the s.s. '' Joshua Nicholson " called at Malta and 
shipped some goats for Antwerp. On the way the crew drank the 
goats' milk unboiled, with the exception of one man (a carpenter or 
engineer), who refused it. At Antwerp they left the goats and shipped 
on a new crew, with the exception of the captain, the mate, the above- 
mentioned carpenter or engineer, and two other men. After leaving 
Antwerp, one of these five men went sick, and had to be landed at 
Gibraltar ; another was very ill at Alexandria, and his blood was sent 
ashore to be tested, and was said to react to Micrococcus melUenfds, They 
proceeded to Odessa, where others fell sick, and by the time they had 
come back to Malta all of the five men were sick with the exception of 
the one man who refused to drink the goats' milk. 

I have written to Horrocks, at Gibraltar, asking him to try to 
trace the man who landed there, and Dr. Stilon is writing to 
Antwerp to get more particulars, which I have asked him for. It 
is most unlikely that the infection was contracted in any other 
way, as they merely stayed here a few hours, and did not, I suppose, 
even land. 

Yours sincerely, 

(Signed) J. Crawford Kennedy. 
Valletta, Malta, 

December U, 1905. 

The EditoTy * RoYAL Army Medical Corps Journal.* 

Dear Sir, — At your request I send a report of a small epidemic of 
Malta Fever, which occurred on board the s.s. "Joshua Nicholson" 
(EUerman Line). On October 21 last, Frederick Jenkins, aged 33, 
steward of the s.s. "Joshua Nicholson," which was anchored in our 
port, was admitted into the Deaconesses' Hospital of our city with the 
clinical signs of Malta Fever. At the request of Dr. Morrison, 
physician of the said hospital, I made a bacteriological examination 
of the blood of this patient (Widal's reaction), with the following 
result: — Positive agglutination with the Micrococcus melUensis in a 
dilution of 1 in 1200; control with the Bacillus typhosus abdominalist 
negative in a dilution of 1 in 50. The result of the bacteriological 



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Epidemiological Work in 1906. 109 

examination thus corroborates the diagnosis of Malta Fever. The 
patient left hospital, cured, on the 4th instant. 

Dr. Morrison had the kindness to draw my attention to the history 
of the case, which is very interesting from the point of view of the 
relation between the infection by the Micrococcus melitensis in man and 
in the goat. Based on these commimications on the part of 
Dr. Morrison, and on the information which I have been able to 
collect from the patient himself, the history of infection in this case 
is as follows : — 

The s.s. "Joshua Nicholson" had, on the occasion of its previous 
voyage, starting from Odessa, anchored about August 19 last for 
about one day in the port of Malta to take on board a flock of 
65 goats, destined for the United States of North America. Seeing 
that the stay of the ship at Malta had only been of so short duration, 
and seeing that, as I am assured, no one left the ship to go on shore, 
it is extremely improbable that the cases of Mediterranean Fever, 
which appeared later amongst the crew of this vessel, could have been 
contracted during the stay at Malta by direct or indirect contagion. 
The ship then continued her course from Malta to Antwerp, where 
she arrived about September 5 last. During the whole voyage every 
one on board (to the total of 24) had drunk fresh milk from the goats 
embarked at Malta. These latter were transhipped two or three days 
after arrival at Antwerp to a ship leaving for a port in North America, 
of which, unfortunately, I have not been able to learn either the name 
or the exact locality. 

The S.S. ** Joshua Nicholson " remained at Antwerp for about two 
weeks, proceeding next to London. It was during the last days of 
the stay at Antwerp, or during the voyage to London (I have not 
been able to obtain exact information on the subject of these dates), 
that four people on board fell sick with fever, whilst during the whole 
of the Voyage from Malta to Antwerp, and during the greater part 
of the stay in the latter port, every one had been in perfect health. 
The sick were : the captain (slightly attacked), the first ofiicer, the 
chief engineer, and the steward. As to the last, I have been able 
to prove, since his arrival here, that he suffered from a typical attack 
of Malta Fever; as to the three others, it has been impossible for 
me to obtain a bacteriological examination of their blood, but I have 
been assured that their clinical symptoms were absolutely identical 
with those observed in the steward. In all probability Malta Fever 
was present in all four cases. In addition, there is a fifth case, a 
certain Swartier (?), treated in the Dreadnought Hospital at Greenwich, 
London, but I have not been able to learn what may have been the 
symptoms of his sickness. Perhaps it would be possible to obtain 
information with regard to him from the authorities of the above 
hospital. It would, indeed, be particularly interesting to know if 



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110 Major McCulloch, Major Weir, and Staflf-Surgeon Clayton. 

this individual also had Mediterranean Fever, for that would prove 
that the case existed, not exclusively in the officers' quarters (captsdn, 
first officer, and where the steward principally carried out his duties), 
but also among the crew. 

To sum up, we find ourselves in the presence of a small epidemic 
of Mediterranean Fever on board a ship which had embarked a flock 
of goats at Malta, and among persons who had drunk unboiled milk 
from these goats. Now, as according to the researches of the Com- 
mission of the Royal Society for the investigation of Malta Fever, 
the goats of Malta are very frequently infected by this malady, and 
as it is proved directly that the Micrococcus meliiefms is secreted often 
in enormous quantities in the milk of these goats, there would be 
nothing surprising in finding that people who had drunk such milk 
had contracted this infection ; besides, this will be the first time that 
this mode of infection in man by the milk of the goat will be directly 
demonstrated. The hypothesis would have more in support if one 
could prove that the above-mentioned Swarder, one of the crew, had 
likewise been attacked by Malta Fever. But if that is not the case, 
we ought not to disguise from ourselves that there may be yet 
another possible way of explaining the infection in this little epidemic — 
it is, that all the four people attacked were in the officers' quarters, 
and were there daily in contact with a passenger, an American, who 
had been several months in Malta bujring the flocks of goats, and 
who accompanied the latter to their destination. Unfortunately, 
I have not been able to get the name of this gentleman. As to his 
state of health, the steward assured me that he was apparently 
always very well — nevertheless, this does not exclude the possibility 
that this gentleman may have contracted Mediterranean Fever during 
his long stay in Malta, and that he may have retained and propagated 
the infection in the latent stage, e.g., by the urine, following the 
analogy of certain convalescents from typhoid fever who, while being 
apparently in perfect health, can for several months propagate the 
infection. Perhaps it may be possible to clear up this question by 
later investigations on the subject of this passenger. 

As regards the goats, which, according to what I have heard were 
destined for establishments for supplying milk to children in America, 
I have drawn the attention of the Consul of the United States in our 
city to the danger likely to ensue under this head. 

Up to the present I have not been able to get further information 
as to what has become of these goats. 

Pray accept, Mr. Editor, the assurance of my esteem. 
(Signed) E. GoTSCHUCH, 
Director of Municipal Sanitary Services of Alexandria. 
Alexandria, 

December 8, 1905. 



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Epidemiological Work in 1906. Ill 

More recent investigation has elicited additional facts in connection 
with the causation of this outbreak, and has also shown that some of 
the details as originally stated were not quite in accordance with 
the actual circumstances. I propose, therefore, to recapitulate the 
facts from the beginning. 

Much of the additional information has been obtained directly from 
the chief of the three goat-herds who accompanied the animals to 
America, and from the captain, chief engineer, and steward of the 
" Joshua Nicholson," who still belong to the ship. 

The History of the Goats. — The entire herd numbered 65, of which 61 
were milch goats. These had been gradually collected in Malta by 
Mr. Thompson, of the Bureau of Animal Industry, U.S.A., who had 
been living in the Island for some months for the purpose. 

These goats were embarked for Antwerp, en route to America, in 
the S.S. ** Joshua Nicholson," which called at Malta on August 19, 
1905, for a few hours. Mr. Thompsofi and three Maltese goat-herds 
accompanied them. The animals were placed in pens on deck in the 
waist, over the after hold, where they must have b6en somewhat 
crowded together from the restricted space available. One milch goat, 
a prize animal — and the finest of the herd — died the day after sailing, 
and was examined post-mortem by Mr. Thompson, who decided that 
pneumonia was the cause of death. 

Except on one occasion the weather during the voyage is said to 
have been good, but as the two assistant goat-herds were seasick most 
of the trip, the goats may possibly have also suffered. At all events, 
there is a discrepancy between the accoimts of the chief goat-herd and 
the people in the ship : the former declaring that all the animals were 
in good health and milking during the entire journey to America, and 
that the total output was about 120 quarts (30 gallons), but the 
latter insist that the supply of milk greatly diminished towards the 
end of the voyage to Antwerp and that the chief goat-herd was much 
concerned and spoke to Mr. Thompson on the subject. This 
information I obtained independently from two persons who entirely 
agreed in their evidence and am therefore inclined to believe that the 
goat-herd's memory fails hi m in this respect ; more particularly as on 
again questioning him with reference to this point he admitted that 
three or four goats did fail to secrete milk when the ship was nearing 
Antwerp. 

Most of the ship's company drank freely of the milk during the 
trip. For those living aft it was collected in a large salad bowl or 
soup tureen which held the milk of three or four goats, but from the 
steward's accoimt, the majority of the men used their own pannikins 
and in consequence often drank the undiluted milk of a single animal. 

The ship arrived at Antwerp on September 2, and the goats were at 
once landed and sent to the quarantine station. Here they remained 



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112 Major McCulloch, Major Weir, and Staff-Surgeon Clayton. 

five days, during which time, by Mr. Thompson's order, the goat-herd 
gave milk from the goats to several persons in and around the station. 

On September 7 the herd was embarked in the s.s. " St. Andrew " 
for passage to New York, Mr. Thompson and the three goat-herds once 
more accompanying them. The goats were accommodated in this 
vessel down below in the hold, and not on deck. The weather 
according to the goat-herd was bad throughout the trip : he further 
states that the 61 goats were still all milking, but as one of them was 
dead, a fact he had evidently forgotten, his evidence cannot be 
accepted as entirely trustworthy on this particular point. The 
captain of the " St. Andrew," however, corroborates him to some 
extent, and says that the total output of milk was about 160 quarts 
(40 gallons). 

With regard to the collection of milk, one utensil appears to have 
been used for the officers and one for the crew, but some of the latter 
at times drank the undiluted milk of a single goat. Most of the 
ship's company seem to have drunk the milk. 

The ship arrived at New York about September 21 to 23, and the 
animals were at once taken to the quarantine station in Athenia, N. J., 
and have been kept in quarantine ever since. Very shortly after their 
arrival, in the early part of October, the urine, blood, and milk of 60 
(the remaining five having died) were examined. The blood of 14 
showed a well marked agglutination reaction with Micrococcus 
melitensiSf 18 more showed an imperfect reaction and 28 gave none. 
A Micrococcus corresponding in morphology and cultural characteristics 
to the Micrococcus meliteTisis was isolated from the milk of two of the 
goats on November 27 and subsequently from that of several more. 
All the goats have been kept constantly in quarantine and the infected 
ones have been killed off from time to time. At present 35 of the 
original goats and 40 kids of various ages remain in quarantine at the 
Government Experiment Station at Bethesda, Md. 

The Incidence of Mediterranean Fever Among those wlw Partook of the MiUc^ 

In the s.s. " Joshua Nicholson." — In this ship there were 23 officers 
and men during the voyage from Malta to Antwerp. Eleven of them 
left the ship ab the same time as the goats and the after history of 
eight of these is unknown, but the remaining three are said by the 
captain to have been later under treatment in hospital at Antwerp 
with very similar symptoms to those from which he and the other men 
suffered. Their names and ratings are: — J. Johansen, carpenter; 
K Olsen, boatswain ; and De Halle, mess-room steward. The only 
one of these men, however, about whom any information is to be 
obtained in Antwerp is Olsen, who was in hospital there, but the only 
medical history is one of hernia. 

Twelve of the original crew were left on board and the following 



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Epidemiological Work in 1906. 



113 



table gives (1) the names and ratings, (2) whether or not they suffered 
from illness, (3) whether such illness was verified by the agglutination 
reaction, and (4) the date of such verification. A more detailed 
account of the after history of each person is given subsequently. 

Table. — Cases of Malta Fever in the Crew of the " Joshua Nicholson,^ 



Name. 


Bank or 


Whether sick 


Whether rerified 


Plaoeand 


rating. 


or not 


by agglutination. 

• 


date. 


A.Cherry... 


Master 


Yes 


Yes 


Malta 4/12/05 


F. SimoncU 


1st mate 


}} 


It 


„ 4/12/06 


D. Smart ... 


Ch. eng. 


»i 


Beacted July/06 


„ 26/7/06 


Unknown ... 


2nd mate 


No 


No 




F. Jenkins 


Steward 


Yes 


Yes 


Alexandria 
21/10/Oft 


A. YisBchers 


Cook 


Yes (stiU sick) 


Not known 


P.Swaters 


A.B. 


Yes 


Yes 


Ghreenwich 
Deoember/06 


Johansen ... 


A.B. 


Yes (ambulatory) 


No 




£. Martin... 


Donkeyman 


Yes 


a 




Spnrgeon ... 
l^ebaok ... 


Engineer 


No 






Jenkins ... 


Cabin boy 


)* 


)> 





The next table gives the movements of the ship during the voyage 
under consideration and for the following few months, which will help 
to make clear the history of these cases. 



Table. — Movements of the " Joshua Nicholson." 


From— 


Date of departure. 


To— 


Date of arriraL 


Malta 


August 19/06 

SefXember 20, 05 

October 1/06 

9/06 

18/06 

27/05 

November 28/05 

„ 80/05 

Deoember 4/05 

January 1/06 

8/06 

16,06 


Antwerp •••••••.• 


September 2/06 
„ 22/05 

October 9/06 
16/06 
21/06 

November 8/05 
80/05 

Deoember 4/06 
17/06 

January 2/06 
16/06 
21/06 


Antwerp ..... 


liOndon 


London 


Gibraltar 


Gibraltar 


Malta 


Malta 


Alexandria 

Odessa 


Alexandria 

Odessa 


Constantinople... 
M.>lfA 


Constantinople... 

Malta 

Antwerp .... 


Antwerp 


liOndon 


London 


Gibraltar 


Gibraltar 


Malta 







Of the 12 persons left in the ship four did not develop any 
symptoms of illness, and will, therefore, be dealt with first. They 
were the second mate, the cabin boy and the two engineers. 

The second mate began drinking the milk, but found that it produced 
constipation and otherwise disagreed with him, and he therefore 
ceased taking it after having had but very little. He left the ship in 
(2089) i 



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114 Major McCuUoch, Major Weir, and StaflT-Surgeon Clayton. 

London some time between September 22 and October 1, apparently 
perfectly well, and cannot now be traced. 

The cabin hoy on this trip was the brother of the steward (who is 
now again in the ship) and has therefore been under observation up to 
the rresent time. The steward states that the milk disagreed with the 
cabin boy also, that he drank hardly any, and that he has had no 
illness. 

The iwo engineers remained in the ship for the next voyage, but never 
had any sickness. They'both drank milk, but told the steward that 
they always boiled it, to which he replied that he did not do so, as 
neither Mr. Thompson nor the captain thought it necessary. 

The remaining eight persons all developed illness with very similar 
symptoms and five at least have given a positive agglutination reaction 
with Micrococcus melUensis, in dilution sufficiently high to eliminate the 
possibility of the reaction being due to other than specific agglutinins. 
In no case could a history of a previous attack of Malta Fever be 
obtained. 

To take these eight persons seriatim : — 

(1) The captain, who drank a great deal of the milk, states that he, 
together with the remaining seven (although the chief engineer and 
steward do not acquiesce in this latter assertion), first began to ail 
about August 31 or September 1, just a day or two before arrival at 
Antwerp. He was not, however, sufficiently ill to prevent him from 
doing duty or to necessitate his consulting a doctor until arrival in 
Constantinople on November 30, although he was noticed by the chief 
engineer and steward to be seedy while at Antwerp, and, moreover, 
was treating himself together with a niunber of the crew while on 
passage from London to Gibraltar and Malta. On November 30 he 
was so ill that he had to consult a doctor ashore at' Constantinople, and 
on December 4 he came under the care of Dr. Stilon at Malta who 
had his blood and that of the first mate examined in the Public 
Health Laboratory, where they were both found to react to Micrococcua 
vielilensis. The captain apparently improved somewhat after this, but 
on the next, voyage out, about January 14, was exceedingly ill, and 
was seen by a doctor ashore at Gibraltar and again by Dr. Stilon at 
Malta on arrival there on January 21. On returning to England from 
this voyage he was under the care of Sir A. K Wright and is now 
well, although his blood serum (July, 1906) still reacts in all dilutions 
up to 1 in 500. 

(2) The first maky like the captain, also drank the milk freely. He 
appears to have been able to carry on his work, and did not see 
a doctor until arrival at Malta on December 4, as already described. 
Subsequently, on the voyage from Malta to Antwerp, he began to 
have '* rheumatic " pains, and, after sustaining an injury, some of his 
joints became swollen. On arrival in London on January 2, he left 



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Hpideniiological Work in 1906. 115 

the ship still unwell, and was under treatment by his own doctor at 
East Ham. 

(3) The chief engineer usually drank the milk diluted with water. 
He was feeling quite well, he says, on arrival in Antwerp, and 
continued in good health imtil he got wet through the day before 
sailing for London, that is, September 19. This resulted in what he 
describes as a succession of colds which he could not shake off and for 
which he was under treatment by his own doctor at Forest Gate from 
September 22 to October 1, when he rejoined the ship. After leaving 
London he began to have various pains about the body and had an 
attack of fever, temperature 102' or 103"* F., for which he was treated 
by the captain. He had pretty well recovered by the time the ship 
was between Malta and Alexandria (about October 20), and has had 
no return of illness, but his blood on July 25, 1906, reacted up to 
1 in 80. 

(4) llie stewardy who says he drank a very great deal of the milk, 
gives the same date for the commencement of his ilhiess as the chief 
engineer, as he independently stated that he was wet through the day 
before leaving Antwerp (September 19) and had as a result severe 
shivering fits and could not get warm. This was followed by profuse 
sweats. He says that he was feeling particularly well on arrival in 
Antwerp, and, in fact, commented on it in writing to his wife. He 
managed to carry on his work until arrival at Alexandria on 
October 21, when he was so ill that he had to be sent ashore to the 
Deaconess Hospital. Here his illness was diagnosed as Mediterranean 
Fever and the diagnosis verified by the agglutination reaction (1 in 
200). He was in hospital till December and then went home by mail 
steamer and rejoined his ship in London. His blood still reacted in 
dilutions up to 1 in 50 in July, 1906. 

(5) The cook also drank the milk and was feeling ill during the 
voyage from London, but was able to continue his work until arrival 
at Antwerp again on December 17, when, being crippled by 
"rheumatism," he was obliged to leave the ship. He attended as an 
out-patient at a hospital there for some time, but got little benefit, and 
when the ship was at Antwerp about May or Jime, 1906, came on 
board for two or three weeks to try to do duty, but was obliged to 
give up. As far as is known his blood has not been tested. 

(6) Swaters, A, B. — The history of this case is given in an editorial 
in the * Journal of the Royal Army Medical Corps ' for February, 1906. 
He appears to have drunk the milk like the others, and gives the date 
of onset of his illness as September 22, when symptoms came on 
suddenly. He was sent to the Dreadnought Hospital on September 29. 
Here a diagnosis was at first made of enteric as he gave a positive 
Widal reaction, but in December he reacted to Micrococcus melUerms, 
and had a typical attack of Mediterranean Fever. 

(2089) i 2 



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116 Major McCulloch, Major Weir, and Staflf-Surgeon Clayton. 

(7) Johansen, A. B, — This man also drank the milk He remained 
in the ship for the voyage to Malta, Alexandria, and Odessa, but was 
complaining of illness all the time, and left the ship at Antwerp on 
arriyal in December. As far as is known, there is no record of blood 
examination. 

(8) Martin, Donkeyman. — This man also drank the milk, but, as far 
as is known, his blood was not examined, and he has left the ship and 
cannot be traced. This was a mild case, and in date of onset, nature 
of symptoms, and duration practically corresponded to that of the 
chief engineer who appears, when in London, to have given him some 
of his own medicine. 

Mr. Thompson, the passenger, is dealt with under heading^ 
'* In America " (see below), and details relating to the three Maltese 
goat-herds are given on p. 117. 

I am informed that for the five days at Antwerp the goats were 
in quarantine the milk was consumed both raw and boiled by the 
persormel of the station, and by many people in the neighbourhood 
with, so far as can be ascertained, no ill effect in any case. These 
persons, it is said, were enthusiastic about the quality of the milk. 

The goats were visited on arrival and departure by the sanitary 
authorities, and were said to be perfectly well. 

In the s,s, " St. Andrew" — The crew of the " 8t. Andrew " numbered 
about 30, most of whom took the milk, and there were on board 
in addition 30 cattle-men returning to the United States who also 
drank it, but up to the present it has been impossible to trace these 
men. It is obvious, therefore, that there wore a great many more 
people drinking the milk than in the "Joshua Nicholson" — some 
60 individuals instead of 23. Both the owners and the master of this 
ship, the latter of whom says that he has had the majority of the 
ship's company under observation up to the date of his letter 
(June 11, 1906), concur in stating that none of the men have suffered 
from any illness. 

In Ameiica, — The Chief of the Bureau of Animal Industry 
states that since the arrival of the goats in America, although a 
number of persons have drunk each as much as a glassful of milk, only 
two persons can be said to have ingested it in any quantity. 

One, the Mr. Thompson who purchased the goats and had been taking 
the milk for some time, died rather suddenly in January, 1906, of 
what was diagnosed bilateral pneumonia following influenza. No 
post-rrwrfem was made, and no blood was obtainable for making an 
agglutination test with Min'ocorcas inetifensi,^. 

With regard to Mr. Thompson, the captain of the *' Joshua 
Nicholson " considers that he was " sickening for something " at about 
the same time as himself and with very similar symptoms, namely, 
slackness and anorexia. Mr. Thompson himself said it was *' liver.* 



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Epideniiological Woi'k in 1906. 117 

The steward states that he did not notice anything definitely wrong 
with him, but that his appetite was poor during the entire voyage. 
Prom his physician's report, however, it would appear that on arrival 
in America he was perfectly well. 

The other person, an unnamed female living in Athenia, N.J., who 
had been drinking mixed milk from several goats daily for a consider- 
able but not very definitely known period, became sick in December, 
1905, with Mediterranean Fever, diagnosed by the clinical symptoms, 
and the fact that her blo(jd serum yielded a positive agglutination 
reaction with Micrococcus melitensis. 



Epidemiological Observations, 

In the ^'Joshua NirlioUon" — The ship is the usual type of cargo 
steamer built in 1880, of 1853 tons gross (1196 tons net), 270 feet in 
length by 35 feet in breadth, with a raised poop and forecastle con- 
taining living spaces for officers and crew respectively, and in the 
waist two hold spaces separated by the engine and boiler rooms. 
Amidships there are deckhouses for the accommodation of part of the 
officers and crew. 

There are, therefore, three separate portions of the ship utilised 
as living spaces, and it will be instructive in connection with the 
possibility of contact infection to consider in more detail the persons 
inhabiting these various portions, and the incidence of illness among 
them. It will, however, be as well to indicate first the possible 
sources of infection and their position during the trip. 

The FossibilUy of Contact Infection, — Mr. Thompson had spent some 
months in Malta, and may possibly have contracted the disease there 
and been suffering from its effects during the voyage ; he lived aft 
under the poop, in a sleeping cabin on the port side of the captain's 
•cabin, the letter's own sleeping cabin being on the starboard side. 

The three goat-herds were natives of Malta, most probably had 
already had an attack of Malta Fever, and may quite conceivably have 
ibeen excreting Micrococcus melitends in the urine, or, judging from 
Shaw's work on the ambulatory type of the disease, had the organism 
•circulating in their blood. It has only been possible to obtain the 
•chief goat-herd's blood for examination (the other two goat-herds being 
«till in America), but this gave a very marked reaction in a dilution of 
1 in 20. A specimen of his urine was also obtained and plated, but no 
Micrococcus vielitensis could be detected. 

All three goat-herds messed and slept on the after hatch close alon^ 
aide the goats. 

Lastly, there were the goats, which, as has already been stated, lived 
in pens placed in the waist, abaft the engine-room and over the after 
holds. How many of these animals were passing Micrococcus mditensis 



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118 Major McCtdloch, Major Weir, and StafiF-Surgeon Clayton. 



LiviMa 



pother A J»^ 
5 Firemen . 



Q,UAK]rCK5 

IN FORECAjdTLC FOR 

6 A-ff5 5FIRtMEN 



Under 

FORECA&TLE 




T^kii'^^^figineen, 

Jioatswain. 

Ccupe/Uer. 



Chl^ goatheriL 
zassCatant 




After 

HOLD 
SPACE 






CaMn ooy* 
MTThompson. 



BERTH T G^P^^'f*^ TCAPTAIN*5 
SALOON 




Under 

POOP 



Sketch'plan of 8.8. " Joehua Nicholson," showing positions where the yarioos 
persons in the ship, during the voyage from Malta to Antwerp,^ meesed and 
slept. Names underlined are known to have subsequently deyeloped'ilbieM, 
and in fiye at least out o£ the number this was yerified as Mediternaiean 
Feyer by the agglutination reaction. 



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Epidemiological Work in 1906. 119 

either in urine or milk or in both during the voyage it is impossible to 
say. 

LocalisaHon of Cases, — Under the poop in the aftermost part of the 
ship there was, abaft the captain's cabin, where he and Mr. Thompson 
lived, the officers' mess, inhabited by the first and second mates. The 
steward and his brother, the cabin boy, also had their meals and slept 
in a cabin down here. 

Of those living in this part of the ship, therefore, the captain, first 
mate and steward contracted the fever, verified in all three cases by 
the agglutination reaction; while the second mate, cabin boy and, 
presumably, Mr. Thompson escaped. 

Amidships was the chief engineer's ^cabin, and the engineers' mess; 
on one side were the quarters of the donkey-man and the cook, while 
on the other side and a little further forward the two engineers, the 
carpenter and boatswain were berthed. 

Of the people living in this portion of the ship, therefore, who still 
remained in her after leaving Antwerp, the chief engineer, donkeyman, 
and cook, were all iU, and the two engineers escaped. Only in one 
of these cases has the diagnosis been verified by the agglutination 
reaction, viz., that of the chief engineer, whose blood still reacted 1 in 
80 when examined in July, 1906. 

Forward under the forecastle were the quarters for five firemen and 
six seamen. Of these, two seamen, Swaters and Johansen, are known 
to have been ill ; in the former case the diagnosis of Malta Fever being 
verified by the agglutination reaction ; the remainder of the men left 
the ship at the same time as the goats, and have since been lost 
sight of. 

Infedion from Urine. — ^Although no Micrococcus melHensis was 
recovered from the chief goat-herd's urine in the one examination 
made, this by no means negatives the possibility that he was passing 
the organism in his urine in August, 1905. Of the persons, however, 
who might have been excreting infective urine, one, Mr. Thompson, 
would use the officers' latrine, while the goat-herds would make use of 
the men's. Similarly, the distribution of illness among those attacked 
would not incriminate any one latrine. As regards the risk of 
infection from the goats' urine, one would expect the barefooted 
seamen who also scrubbed the deck to be more liable to inoculation 
than the booted officers. Convection by flies is of course a possibility, 
but as the ship sailed at once, it is decidedly unlikely that flies or 
other insects remained long on the upper deck where the goats were 
located. 

Infedionfrom Biting Flies. — Though possible, the distribution of the 
cases in all parts of die ship, and the fact that she was only a few 
hours in Malta, moored in the stream, and put to sea at once, renders 
this distinctly improbable. 



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120 Major McCulloch, Major Weir, and Staflf-Surgeon Clayton. 

Infection from Ingestion of Milk, — This is the one common factor, and 
its probability is immensely strengthened by the two facts that all 
who are known to have taken little mOk, or to have boiled the milk 
before drinking it, escaped, and that one of the only two persons who 
drank it to any extent in America, far from the endemic area and 
almost removed from the possibility of contact infection, contracted a 
typical attack. 

At Antwerp, — It is difficult to understand why the persons who 
drank the milk at Antwerp escaped infection. It must, however, l)e 
remembered that it was taken at the most for a period of five days, and 
that two separate informants in the " Joshua Nicholson " say that the 
goats had largely ceased to secrete milk at the end of the trip from 
Malta. As the Micrococcus could only be isolated from the milk of 
two when first examined in America (in November, two months after 
arrival), it does not seem improbable that those piissing the cocci should 
either have ceased to do so at this time, or that the number excreted 
should have very greatly diminished. Moreover, it is not altogether 
unreasonable to suppose that these animals, infected by the Micro- 
coccus and not therefore in a normal condition of health, would l)e 
among the first to respond to any conditions adversely affecting the 
secretion of milk. 

In the " St. Andrew," — ^This is far more difficult to explain, but certain 
facts must be taken into consideration. In the first place, the voyage 
was one across the Atlantic, and more stormy weather was met with 
than in the "Joshua Nicholson." In the second, the ship was no longer 
in the subtropics, but in wintry northern seas, and, finally, the goats 
were below in a stuffy hold and not on the upper deck. 

The possibility that the secretion of the milk was interfered with is, 
therefore, considerably greater than in the " Joshua Nicholson." Again, 
the number of persons amongst whom the milk was distributed was 
almost three times as large as that comprising the crew of the 
" Joshua Nicholson," consequently the amount of milk available per 
head, even supposing the goats were yielding as well, would be much 
diminished. 

In America, — In this case there was no possibility of previous 
exposure, and infection by contact is far less probable than in the ship. 
Mr. Thompson went to Washington the day after arrival, so that he, 
as a possible source of infection, can be disregarded. The goat-herds 
and the goats themselves were at the quarantine station, but the 
patient could not have been exposed to the same chances of contact 
infection as those in the ship. On the other hand, there is the positive 
evidence that she had drunk a considerable amount of milk from 
various goats of the herd, and that this probably insluded infected 
milk. 

Duration of Period between Ingestion of Goats* Milk {some of whicli was 

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Epidemiological Work in 1906. 



121 



undaubUdly infective) and the Development of Symptoms, — Assuming milk 
to be the vehicle of infection, the following table gives the interval in 
•days which intervened between the time during which the milk was 
being consumed and the first development of symptoms in the three 
cases in which this latter point is definitely known. 



Table. 



Name. 


Dates of ingestion of milk. 


Date of onset. 


Interval. 


D. Smart 

F.Jenkins 

Swaters 


Between Aug. 19 and Sept. 1 


Sept. 19 
,, 22 


31 to 18 days 
31 „ 18 „ 
84 „ 21 „ 





In conclusion, I have to acknowledge the kindness of Mr. Grout, of 
the American Consular Service in Valletta, who not only first enabled 
me to see the chief goat-herd and trace the goats, but also gave me 
much assistance otherwise. I am also indebted for much information 
to Dr. A. D. Melvin, Director of the Bureau of Animal Industry, 
U.S.A.; to Messrs. O. F. GoUcher, agents for the Westcott and 
Lawrence line in Valletta ; to Captain Cherry, the chief engineer and 
steward of the • Joshua Nicholson " ; to Messrs. Rankin, Gilmour and 
•Co., the owners, and Captain Fitzgerald, the master of the "St. 
Andrew " ; and to Sir Cecil Hertslet, His Majesty's Consul-General at 
Antwerp, who has been kind enough to obtain the information required 
in that place. 



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122 Major McCulloch, Major Weir, and Staff-Surgeon Clayton- 

DivisiON II.— MILITARY. 

By Major T. McCulloch, M.B., and Major J. C. Weir, M.B., Royal 

Army Medical Corps. 

SYNOPSIS OF OONTEirrS. PAOK 

Skction L — Iktboductobt— Statistical Data, etc 128 

1. Continaed feven in Malto from 1861 to 1905 124 

(1) Bolation to sanitarj conditions 127 

(2) Belfttion to ttrength of garrison 12S 

(8) Cyclical periods „ 12^ 

(4) Extent of prevalence of continued fevers 131 

(5) Comparison of Malta and Gibraltar 131 

2. The period of separate statistics 134- 

(1) The prevalence of Mediterranean, simple continaed and enteric 

fevers in Malta from 1897 185- 

(2) The relation of simple continaed fevers 136- 

(8) The relation of enteric fever 142 

(4) Prevalence of Mediterranean Fever in Malta from 1897 to 1906 144 

3. Prevalence of Mediterranean Fever in diiferent branches of the service ISO 

(1) ArtiUery and infantry compared «. ISO- 

(2) Special prevalence in the Royal Army Medical Corps 150 

(8) Interval between arrival of iinits and first appearance of oases 157 

(4) Prevalence amongst officers, women and children 158- 

(5) Age and service in Malta in relation to Mediterranean Fever.^. IQO 

(6) Climate in relation to Mediterranean Fever 162 

Section II. — Miditibbakkak Fetkb in the Gabbison in .1906 163 

Preliminary remarks 163- 

1. Drainage, barrack supplies, etc 166- 

2. Investigation of milk supplies 166- 

(1) Milk precautions prior to the milk change 16& 

(2) Failure of sterilisation 169 

(3) Laboratory examinations of milk 170 

(4) Cases with a common milk supply 170 

(6) Examinations of goats 17C> 

(6) Discontinuance of the use of goats' milk in hospitals and 

barracks I7a 

3. Distribution of cases 17* 

4. Prevalence in units 177 

6. Analysis of cases 17^ 

(1) Series 1. — The cases in the Ist Battalion Royal West Kent 

Regiment 181 

(2) Series 2. — ^The cases in the Royal Army Medical Corps 192" 

(8) Series 8. — Hospital cases IftS 

Examinations of the diet sheets of patients in Valletta 

Hospital during 1905 201 

(4) Series 4.— Other cases of possible milk infection 20& 

(5) Series 5. — Cases in which the patients were probably infected 

through animals other than goats 208- 

6. Occupation in relation to attack 2q^ 

7. Prevalence amongst officers 210 

8. Prevalence in married quarters 211 

9. Mosquitoes, etc 213 

10. Preventive measures 214 

11. Results of work in 1906 ] * 2ia 



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Epidemiological Work in 1906. 123 

Division IIL— CIVIL. pa&b 

1. ProTalence amongst the ciril population 227 

2. Age and sex in relation to attack , 228 

3. The relation of goats to the incidence of the disease 288 

4. Goats* milk as a factor in the causation of Mediterranean Fever amongst 

the ciril population. By Dr. A. Cbitiek, of the Public Health 
Department, Malta 286 

GENERAL SUM^IARY. 

i. The incubation period 244 

ii. A critical examination of naval, military, etc., observations 250 

iii. Recommendations 266 

Division II.— MILITARY. 
Section I. 

The view is still current in Malta that Mediterranean Fever is, 
comparatively speaking, a disease of recent appearance in the island. 
The old contention that it was introduced by troops from the Crimea 
appears to have died out, but it is still asserted by some that the 
disease originated when the new drainage system was laid down in 
1886. Hughes quotes evidence in his historical account of the disease 
which goes to show that, although unrecognised as a separate entity, it 
was one of the diseases of Malta as far back as the beginning of last 
century, and it is possibly of much greater antiquity. An old 
manuscript book in the Principal Medical Officer's office at Malta 
contains a health report, dated June, 1818, in which the surgeon of the 
8th King's Regiment of Foot states that the regiment landed in Malta 
on March 2, 1818, and took up quarters in the barracks at Floriana. 
Soon afterwards, cases of fever began to occur, one or two being of 
great severity, and the description given of the symptoms bears a close 
resemblance in many respects to the disease as described at the present 
day. That Mediterranean Fever formed one of the diseases included 
under the heading of continued^fevers in the period 1861 — 1870 is 
certain. For example, it is noted in the Army Medical Department 
Report for 1866 that the fevers of the year were characterised by 
tedious convalescence and the frequent occurrence of orchitis and 
rheumatism as sequelse. It may be worth mentioning here that 
Hennen, who was in Malta from 1816 to 1825, in his book on the 
" Medical Topography of the Mediterranean," draws attention to the 
fineness of the goats in Malta, and to the excellence of the milk they 
furnished. 

No attempt was made in the writings of the earlier army medical 
ofiBcers to distinguish Mediterranean from other fevers of continued 
type, and it was only after the Crimean War that the distinction began 
to be made. The first accurate description of the disease was given by 
Marston in the Army Medical Department Report for 1861, under the 



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124 Major McCulloch, Major Weir, and Staff-Surgeon Clayton. 

ieading of Mediterranean remittent or gastric remittent fever. The 
<liscovery of the Mtaococcus meHiensis in 1887 definitely established the 
iact that Mediterranean Fever was a distinct disease, and this was 
recognised hy its being included in the official Nomenclature of Diseases 
in 1897, from which year it was given .i separate place in army 
statistical returns. It should not bo lost sight of, however, that long 
previous to this a very exact knowledge of the cliiiieal fe^itures of the 
disease had hecn gained from years of observation of cases ; for example, 
Bruce was able to obUiiii records of the admission of 627 cases to 
Valletta Hospital during the 12 yeiirs 1876 to 18.87. Prior to 1897, 
Mediterranean Fever was included with simple continued fever in 
official returns under the heading of " Other Continued Fevers," enteric 
having been shown as a separate disease since 1882, before which year 
the heading of "Continued Fevers" included enteric, Mediterranean 
jind simple continued fevers. Consequently, although records of enteric 
prevalence can be obtained as far back as 1882, records in which 
Mediterranean and simple continued fevers are separately shown only 
begin with the year 181)7. It follows that, in making compiirisons of 
recent with old statistics, it is necessary to do so on a "Total of 
Continued l''\ ers " basis. 

Mcditeri anean Fever statistics require to be brought up to date, as, 
up to the ] resent, the only readily available compilations are those 
^ven by HughovS, ending with 1895, and published in his book in 1897. 
Hughes' tal*ks deal with the periods when it was impossible to split up 
** Continued Fevers " into the component parts, and they end at a time 
when the ])revalence of continued fevers appeared to be on the decrease, 
whereas they have since shown a strong upward tendency. A con- 
siderable amount of attention has, therefore, been given to statistical 
details, and particularly to those of the period beginning with 1897, 
when separate Mediterranean Fever statistics were first obtainable. 

1. Continued Fevers in Malfufrom 1861/0 1905. 
The earliest statistical data relating to the prevalence of continued 
fevers in Malta which we have been able to find are for the period 
I813to 1818, when the admission rate was 89*1 and the death rate 
1*88 per 1000. As time went on, continued fevers manifested a 
ateadily increasing prevalence amongst the troops. Thus, in the 
decennial period 1836 — 1847, the admission ratio had risen to 207*3 
per 1000, with a death rate of 1*46. In 1859, the prevalence of these 
fevers reached its culminating point with an admission ratio of 269*5, 
and this is still the highest on record ; the same is true of the death 
rate, which was 8*85 per 1000. The following comments appear in the 
Army Medical Department Report for the year : — " Although there has 
been a slight increase in paroxysmal fevers and rheumatism, the great 



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Epidemiological Work in 1906. 



125 



difference, both in the number of cases and deaths, has been attributable* 
to fevers of the continued type. The excess in 1859 over the previous 
average amounting to 62 per 1000 in the admissions, and 7*4 per 1000* 
in the deaths. The disease appears to have become more than usually 
prevalent in the second quarter of the yt ar, to have reached its maximum 
in the third, but to have caused the greatest number of deaths in the- 
fourth quarter. The fever w,ns of typhoid type, and of a very fataF 
character, the deaths amounting to 1 in 28 of all the cases, while in- 
the 23rd Regiment they were as high as 1 in 20, and in the 4th Rifle- 
Brigade 1 in 18. On the average of the 10 years 1837 — 1846, con-^ 
tinued fever proved fatal to only 1 in 141 cases." The hitrh mortality 
and its occurrence at the close of the year indicate an enteric epidemic 
grafted on to the ordinary fever prevalence. Of the six regiments, the- 
only corps which appears to have enjoyed a marked exemption from the- 
disease was the 1st Battalion 21st liOgiment, the only old battalion 
serving in the island, while by far the highest proportion of admissions^ 
but with a moderate death rate, o*-curre(l in the 2n(l Battiilion 22nd 
Regiment, which arrived from England in the end of May, just as the- 
hot weather set in. Overcrowded barracks and a hot dry season were^ 
accompanying conditions. 

The following table shows the prevalence of " Continued Fevers " in* 
Malta up to the end of 1905. For purposes of comparison, the ratios^ 
of admissions from all causes are given, as well as the corresponding 
statistical data relating to Gibraltar. The ratios are arranged im 
decennial periods from 1861 to 1900, followed by the quinquennial 
period 1901 to 1905. 

Table I. 
Malta. 





All causes. 


Continued fevers. 


1 












Proportion of 












continued 


Period. 


Ratio per 1000. 


Ratio per 1000. 


fcTors to 












, admissions 
from all causes. 


1 




1 






Admissions. 


Deaths. 


Admissions. 


Deaths. 














. per cent. 


1813—18 


— 


— 


89-1 


1-88 


' — 


1887-46 


— 


— 


207-3 


1-46 


1 


1859 


1213-9 


19-02 


209 -5 


8-85 


22 


1860 


983-0 


10-59 


208-6 


3-87 


1 21 


1861—70 


798-1 


18-49 


172 7 


8-09 


1 22 


1871-80 


857 -1 


9-77 


155-3 


2-56 


; 18 


1881—90 


698-7 


8-70 


122-4 


8 36 


17-5 


1891—1900 


784-7 


7-56 


171-6 


8-58 


22 


1901—05 

Ratios 
1861—1905 


646 1 


6-32 


174-3 


2-50 


27 


I 702 -2 
J 


9-13 


159 -8 


3-09 


21 

t 



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126 Major McCuUoch, Major Weir, and Stafif-Surgeon Clayton. 

Gibraltar. 





All oaiises. 


Continued fevers. 














Proportion of 
continued 










Period. 


Ratio per 1000. 


Ratio per 1000. 


f cyers to ' 












admissions 1 










from all causes. 




AdmiBsions. 


Deaths. 


Admissions. 


Deaths. 














per cent. 


1813—18 


— 


— 


— 


— 


— 


1887—46 


— 


— 


75-6 


1-87 


— 


1869 


940*0 


7-18 


107-6 


2-91 


11 


1860 


826-0 


11-06 


69-4 


1-07 


7 


1861—70 


742-6 


8-44 


72-9 


1-60 


10 


1871—80 


676-8 


6-66 


87-9 


1-28 


18 


1881—90 


800-4 


6-01 


106-9 


2*24 


13-6 


1891—1900 


718-6 


4-00 


20-3 


1-01 


2-8 


1901—05 

Ratios 
1861—1906 


362-8 


3-71 


9-6 


0-69 


2-7 


. 692-9 


6 01 


66-1 


1-42 


9-4 



The chief points which this table brings into prominence are as 
follows : — 

1. The great prevalence of continued fevers in Malta. 

2. The increase in prevalence in recent years. 

3. That, although the general decennial admission ratios (all causes) 
show comparatively little change since 1861, there has been a gradual 
but steady decrease in the corresponding death rates. 

4. That the decennial death rates from continued fevers for the same 
period show no improvement. 

5. That the health of the garrison of Malta compares unfavourably 
with that of Gibraltar, especially as regards prevalence of continued 
fevers. 

6. That there has been a remarkable disappearance of fevers of 
continued type (except enteric) from Gibraltar, and this has taken place 
in the course of the last 20 years. ^ 

Concerning the increase of continued fevers which occurred in the 
second and part of the third quarters of last century, reaching its 
highest point in 1859, we have nothing to say. The thirty years 
1861 — 1890 are marked by a decreased prevalence of continued fevers, 
as evidenced by ratios of 172*7, 155*3, and 122*4, for the successive 
decennial periods. The next fifteen years showed a very considerable 
increase in fever prevalence, the decennial ratio for 1891 — 1900 being 
171*6 per 1000, and this was followed by a further increase to 174*3, 
the average rate observed during the five years 1901 to 1905. During 
the thirty years' period of decrease the strength of the garrison averaged 



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Epidemiological Wwh in 1906. 127 

about 5200, while the average strength for the ten years 1891 — 1900, 
was about 7800, and for the five years 1901—1905 just over 8000. 
At the close of the second decade of the period of decrease an unsettling 
factor is introduced into the question, namely, the short service system, 
which would cause a greater circulation of men and, therefore, a 
corresponding increase in the quantity of susceptible material. A 
reference to Chart 1 will show that this change was associated with 
increased prevalence of enteric fever. Indeed, during the four years, 
1882 — 1885 enteric fever was higher than it has ever been either 
before or since. But the change does not appear to have exercised any 
immediate effect on the prevalence of the other continued fevers, i.e., 
simple continued and Mediterranean Fevers. In fact, three of the 
years when enteric was so prevalent, 1882 — 1884, are years when the 
prevalence of the other continued fevers was light, while the five years 
1887 — 1891 are remarkable as being the years showing the lowest 
prevalence of continued fevers which has occurred during the entire 
period from 1861 to 1905. 

(1) RdaUon to Scmiiary Conditions. — That a factor altogether outside 
ordinary sanitary defects must exist to account for the increase in 
prevalence of continued fevers in recent years seems more than 
probable, when it is considered that the soldier must have been living 
under far better conditions, and with far better sanitary surroundings, 
during the fifteen years 1891 to 1905 than those that obtained during 
the greater part of the thirty years 1861 to 1890. Yet, the 1891 to 
1905 period was marked by a largely increased prevalence of these 
fevers. In the Army Medical Department Report for 1861, the 
following comment is made, in a reference to the opening of new 
stone barracks at Pembroke Camp, St. George's Bay, " that they must 
prove a valuable relief to the hitherto densely packed garrison of 
Malta." And, in connection with the erection of two wooden huts at 
Upper St. Elmo, we are informed, that they were much required, for 
the barracks, generally^ throughout the garrison^ are imperfect in their 
means of ventilation, limited in respect of their cubic space, 
objectionably situated for their health as an especial question, and had 
imperfect drainage. In another part of the report, the Principal 
lledical Officer, when reviewing the sanitary conditions generally, 
remarks that, barracks being throughout the command within the lines 
of fortification, old structures built by the " Knights " and connected with 
the defences, they are iU-ventilated and often damp, and much of the 
disease which occurs in the gam'son is engendered by them. Con- 
sistent with their present construction, although capable of much 
improvement, it is thought they never can be placed on a high 
sanitary footing suitable to the climate; and he advances for 
consideration, whether the erection of quarters outside the walls, for 
occupation in time of peace, would not be attended with satisfactory 



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128 Major McCulloch, Major Weir, and StafT-Surgoon Clayton. 

results, not only in a sanitary, but also in a financial view. The- 
barracks, at this time, are also described as cheerless, badly lit and iU 
warmed. From very early days the overcrowded barracks were^ 
relieved in the hot season of a portion of their occupants by pitching 
tents, and it is several times recorded that this measure always 
appeared to be followed by a lessening of sickness in the barracks 
concerned, while it is also stated that the type of case from the tents 
was less severe than cases from the barrack rooms. Such, then, were^ 
some of the conditions under which soldiers were living in the early 
part of the thirty years' period of decreased fever prevalence, and, 
although sanitary improvements were made in those old barracks as 
years went on, no new barracks were opened between 1861 and 1896. 
Towards the close of this period two great sanitary advances were^ 
made, in the remodelling of the drainage of Valletta in 1885, and in 
the provision of a better water supply in 1887. New barracks were 
built and were opened at Imtarfa in 1896, Tigne in 1901, New 
Floriana (A, B, and C blocks) in 1903 and St. Andrew's Barracks^ 
Pembroke, in 1905. Yet, notwithstanding general sanitary improve- 
ments in old barracks and the provision of new barracks, and that the^ 
clothing and feeding, as well as the general environment of the soldier 
have been altered greatly for the better since the sixties and seventies^ 
continued fevers increased in prevalence during the decennial period 
1891 to 1900, and increased still further in the five years 1901 to- 
1905, the ratio for the latter period being 174*3 per 1000, or 1-6- 
higher than the decennial ratio of 1861 to 1870. Even granting that 
there was still much sanitary deficiency remaining in the 1891 to 
1905 period, surely it cannot be maintained that the sanitary condi- 
tions were worse than in the preceding thirty years. That sanitary 
improvements were exercising a beneficial effect on the general healtii 
conditions of the troops is rendered evident by consideration of the 
death rates from all causes (Table I), from which it will be observed 
that the death rate of 13*49 per 1000 for the decennial x>eriod 1861 to- 
1870 had fallen to 6*32 per 1000 for the five years 1901 to 1905, and 
that the descent has been gradual and progressive for each succeeding 
decennial period. Table I also shows that there has been no* 
con'esponding decrease in the fever death rates, in fact there has been 
little or no change, which consideration appears to indicate that 
sanitary improvements have not exerted any influence in diminishing 
the severity of type of these fevers, and, as we have seen, the- 
incidence has increased. 

(2) JRdaUon to Strength of Garrison. — As already pointed out, there 
was a very marked difference in the strength of the garrison in the^ 
two periods. The annual average strength for the period from 1861 
to 1890 was about 5200, while for the 10 years 1891 to 1900 it 
averaged about 7800, and for the five years 1901 to 1905 just over 



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I!pidei)iiological Work in 1906. 129 

8000. On examination of the yearly strengths from which these 
averages are calculated, it is observed that for by far the greater part 
of the thirty years' period the annual strength was generally under 
5000 men, and often considerably under that number. In 1887 the 
strength began to be increased, the average strength for that year 
being 5499, and each year troops were added gradually to the garrison 
until a strength of 7055 was reached in 1890, of 7847 in 1892, and of 
8292 in 1895. As no new barracks were available until 1896, 
accommodation for the additional 2000 to 3000 men had to be found 
in existing barracks, which may have meant overcrowding. Nothing 
happened during the first three years, 1887 to 1889, in fact they were 
exceptionally healthy years. But in 1890, when the strength had 
reached just over 7000 men, enteric fever became more than usually 
prevalent, and there was large enteric prevalence in 1893. The 
sustained increase of the continued fevers, as a whole, dates from 
1892. 

(3) Cyclical Peiiods. — Hughes has pointed out that continued fever 
prevalence appears to run in definite cycles, and he defines a cyclical 
period as the period which extends from one maximum year of 
prevalence to the next maximum year. Chart 1 shows that the years 
of maximum prevalence were 1859, 1867, 1872, 1879, 1885, 1892, 
1898, and 1905, the intervals being eight, five, seven, six, seven, six, 
and seven years respectively. The first five of those cyclical periods 
showed decrease, the last two increase of fever prevalence. We are 
unable to give any exact evidence as to what determines this apparent 
periodicity. We do not know which of the forms of continued fever 
have played the chief part in it, or whether they have all had a share. 
We fa)ow that cyclical prevalence is observed in other diseases, and it 
may be the case here also, that after the main part of the susceptible 
material, present for the time, has been used up, an interval must 
pass during which fresh material is accumulating. In a military 
station like Malta there is necessarily frequent movement of troops ; 
regiments and drafts are constantly coming and going. New arrivals 
probably always bring a fresh accession of susceptible material In 
some years there is less fluctuation than in others, and the garrison is 
for a short period correspondingly more stable. It is easy to under 
stand that at some periods there may be unusually large accumula 
tions of susceptible individuals, but it is thought that this would be 
more likely to show itself in a military population by irregular 
outbursts rather than by more or less well defined cycles. For 
example, Chart 1 shows an outburst of fever in Gibraltar during the 
years 1881 to 1885, which may have been contributed to by an 
unusual accession of susceptible individuals. We are told, in regard 
to one of the years, that the garrison contained many young soldiers, 
and the increase of fever in the years in question occurred in a period 
(2089) k 



Digitized by VjOOQIC 



130 Major McCuUoch, Major Weir, and Staff-Surgeon Clayton- 



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Epidemiological Work in 1906. 131 

shortly after the introduction of the short service system. Attention 
should he paid to the fact that cyclical periodicity is not a feature of 
the Gibraltar part of this chart. 

(4) Extmi of Prevalence. — During the forty-five years 1861 to 1905 
the continued fevers (simple continued, Mediterranean, enteric) have 
been the cause of 21 per cent., or just over one-fifth, of the total 
admissions to hospital from all causes in Malta, and they have also 
been responsible for just over one-third of the total number of deaths. 
In Gibraltar, for the same period, these fevers have been the cause of 
9*4 per cent., or just less than one-tenth, of the total admissions to 
hospital, and they have caused about one-fourth of the total deaths. 

(5) Comparison of Malta and Gibraltar, — The general health of the 
garrison of Malta also compares unfavourably with that of Gibraltar 
(t'ide Table I). The decennial admission ratios from all causes are 
lower in the case of the latter, except for the decennial period 
1881 to 1890, when the ratio was 8004 per 1000 for Gibraltar against 
698*7 for Malta. The Gibraltar death rates are uniformly lower than 
those of Malta. It is a notable circumstance that the ten years 

1881 .to 1890 show the highest prevalence of continued fevers on 
record for Gibraltar, whereas it was the period when the prevalence 
of these fevers was at its lowest point in Malta. 

It will be observed {vide Table I) that commencing with the 
decennium 1861 to 1870, the prevalence of continued fevers in 
Gibraltar showed steady increase from 59*4 per 1000 until it reached 
108*9 in the ten years 1881 to 1890, so that increase was the order of 
things in Gibraltar during the thirty years thaf decrease was occurring 
in Malta. In Gibraltar, during the first five years of the 1881 to 1890 
period, there was a remarkable increase in prevalence of continued 
fevers, which then reached the highest point ever observed in this 
station, the highest ratio on record being that of 197*9 per 1000 for 
1882, while the ratio for 1881 was 164*3, and the ratios for 1883, 
1884, and 1885, were 171*4, 176*8, and 160*0, respectively. The 
increase appears to have been chiefly in continued fevers, other than 
enteric, as, although enteric was rather more than usually present in 

1882 and 1885, no special enteric prevalence was observed in 1883 or 
1884. During the second five years of this period the very opposite 
was observed. In 1886, a large outbreak of enteric fever occurred, 
regarding which it is stated, that the disease was introduced by 
H regiment which had lately come form Egypt to Gibraltar, and for 
the next three years enteric was unusually prevalent. During these 
four enteric years there was a great lessening of the other continued 
fevers, their prevalence being reduced to about one-fifth of what it was 
for the four immediately preceding years, 1882 to 1885. The figures 
for the decennial period are as follows : — (see also Chart 1). 

(2089) I' 2 

Digitized by VjOOQ IC 



132 Major McCuUoch, Major Weir, and Staflf-Surgeon Clayton, 
Gibraltar, 1881—1890. Ratios per 1000. 



Year. 


Enteric fever. 


Other 
continued ferers. 


Total 
continued feyers. 


1881 


Not known 


Not known 


164 8 


1882 


8-8 


189-1 


197-9 


1883 


2-6 


168-9 


171-4 


1884 


0-6 


176-2 


176-8 


1885 


6-7 


164-3 


160-0 


1886 


36-7 


40-2 


76-9 


1887 


7-6 


22-7 


80-3 


1888 


15-4 


27-7 


43 1 


1889 


9-0 


28-8 


87-8 


1890 


5-6 


80-5 


86 1 



Absolutely certain evidence as to the cause of the great increase of 
fever prevalence during the first half of this decennial period is, as 
might be expected, impossible to obtain, but it may be stated that it 
coincided in point of time with the introduction of the short service 
system, and Horrocks, in his paper on ** Mediterranean Fever in 
Gibraltar" (Part V of the Commission Reports) points out the 
significant fact, that in 1883 practically all the goats on the Rock 
were Maltese, and also, that at that time regular shipments of goats 
from Malta to Gibraltar took place. 

In Chart 1 the prevalence of continued fevers in Malta and 
Gibraltar from 1859 to 1905 is contrasted, and a most extraordinary 
contrast is observed between the fever records of the two 
Mediterranean stations during the twenty years 1886 to 1905. In that 
time, Mediterranean Fever has almost completely disappeared from 
Gibraltar, and coincident with its disappearance there has been 
a most remarkable lessening in the prevalence of simple continued 
fevers. On the other hand, in Malta, during the same period, there 
was very great prevalence of these fevers. 

The disappearance of these fevers from Gibraltar began somewhat 
abruptly in 1886 and, as already stated, 1886 particularly, and the 
three following years to a less extent, were years in which enteric 
was more than usually prevalent. Since that time up to 1905, 
although the enteric ratios have been moderate, the prevalence of the 
disease has been steady. The conditions, therefore, which were 
bringing about the disappearance of Mediterranean and simple 
continued fevers were apparently not affecting to any considerable 
extent, if at all, the prevalence of enteric. It seems worth noting 
here that the Army Medical Department Report for 1892 gives the 
information that all the milk for the troops in Gibraltar was then being 
boiled as a preventive measure against enteric fever. 

The following are the ratios for Mediterranean, simple continued 



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Epidemiological Work in 1906. 



133 



and enteric fevers for Gibraltar from 1897, the year from which the 
statistics are first given separately in army returns : — 

Gibraltar, 1897—1905. Eatios per 1000. 



Year. 


Mediterranean 


Simple continued 


Enteric 


Fever. 


fever. 


fever. 


1897 


4-0 


10 1 


3-4 


1898 


6-8 


11-2 


4-2 


1899 


4-2 


4-7 


2 1 


1900 


2 


6*8 


4-8 


1901 


2-4 


4-1 


3-6 


• 1902 


1-0 


2-2 


3 1 


1908 


1-9 


6-8 


2-3 


1904 


— 


4-8 


2-9 


1905 


0-7 


9 1 


41 



It will be observed from a consideration of these ratios, or, better 
still perhaps, by a glance at Chart 1, that there was a second small, 
but still well marked, decrease of Mediterranean fever prevalence in 
1900 in Gibraltar, that the ratio was very low in the next three years, 
and that there were no cases at all in 1904. The ratio of 0*7 for 
1905 represents only three admissions for the disease, and in regard 
to two of the cases it was stated that the men had lately arrived in 
a draft from Malta, and had in all probability contracted the disease 
there. The third was a man employed as a military policeman, who 
had been in Gibraltar for five years, and in this case the probable 
source of the disease could not be traced. In 1906 there have been 
no cases of Mediterranean Fever in Gibraltar up to the end of 
November. 

The simultaneous disappearance of so much of the simple continued 
fever seems to indicate that a common factor, or factors, had been 
removed, or at any rate, greatly lessened, and also that many cases 
which were returned as simple continued fever may have been mild 
cases of Mediterranean Fever. The disappearance of Mediterranean 
Fever from Gibraltar is discussed by Major Horrocks in a paper 
(Part V, Commission Eeports) already referred to, with which is a chart 
showing a probable connection between reduction of the number of 
infected goats and the decrease of fever. From this paper we obtain 
the two following important facts : — 

(1) That, as a result of the withdrawal of grazing passes, the 

number of goats was reduced. 
It was ascertained that from 1883 to 1893 about 1100 goats were sold. 

(2) Pari passu with the withdrawal of grazing passes, and increase 

in the cost of shipment, importation of goaXafram Malta on a 
large scale ceased. 



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134 Major McCuUoch, Major Weir, and Staff-Surgeon Clayton. 

Goatkeepers replaced their stock partly by importation of Spanish 
goats, and partly by breeding. 

Horrocks concludes his paper in the following words : — " It appears 
probable that the rapid disappearance of Mediterranean Fever from 
Gibraltar, which commenced in 1885, was intimately connected with 
the exodus of infected goats from the Rock. Improved sanitary 
conditions, especially the disconnection of waste-pipes and house-drains 
from sewers, may have played a part in causing the decrease of fever, 
but as the same sanitary improvements have been carried out in Malta 
without any corresponding decline of Mediterranean Fever, it is fair to 
assume that their effect was insignificant compared with that produced 
by the removal of infected goats." 

2. The Period of Separate Statistics. 

Table II gives the statistics of Mediterranean, simple continued, 
and enteric fevers for Malta from 1897. 



Table n. 



Year. 


.ir 


Mediterranean 
Fever. 


Simple 

continued 

fever. 


Enteric 
fever. 


Total 
continued 
fevers. j 


Adm. 


D. 


Adm. 


D. 


Adm. 


D. 


Adm. 


D. 


1897 
1898 
1899 
1900 
1901 
1902 
1908 
1904 
1906 
1906 


8028 
7890 
7425 
8140 
8186 
8768 
8903 
9120 
8294 
6661 


279 
200 
276 
168 
253 
165 
404 
820 
648 
168t 


12 
8 
9 
8 
9 
6 
9 
12 
16 
1 


1276 

1509 

1107 

1168 

1206 

981 

781 

1350 

1199 

604 


1 


34 
62 
41 
31 
41 
38 
18 
79 
64 
9 


15 

24 

17 

11 

11 

4 

8 

16 

17 

1 


1588 
1771 
1428 
1347 
1499 
1174 
1208 
1749 
1906 
676 


27 
33 
26 
19 
20 
10 
17 
28 
38 
2 



* Excluding Crete. 



t Including 19 re-admiBsions. 



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Epidcraioloijical Work in 1906 
Batios per 1000 of Strength. 



135 



Year. 


Mediterranean 
FeTer. 


Simple 

continued 

fever. 


Enterio 
fever. 


Total 

continued 

feyers. 


Adm. 


D. 


Adm. 


D. 


Adm. 


D. 


Adm. 


D. 


1897 
1898 
1899 
1900 
1901 
1902 
1903 
1904 
1905 


847 
27 1 
37-0 
19-4 
31 1 
17 7 
46-4 
36 1 
77-6 


1-49 
1-08 
1-21 
0-98 
110 
0*68 
101 
1-32 
1-93 


158-9 
204*2 
149 1 
142-2 
148 1 
112-0 
87 7 
148-0 
144-6 


0-13 


1 
4-2 . 1-88 
8-4 I 3-25 
6-5 2-29 
3-8 1-36 
5-0 1-23 
4-3 0-46 
2-0 0-90 
87 , 176 
77 ! 2-06 


197-9 
239*6 
191-6 
166-6 
184-2 
134-0 
135-1 
191-8 
229-8 


3-36 
4-46 
3*50 
2-33 
2-46 
1*14 
1-90 
3-07 
8-98 


BatioBfor 1 
1897—1905/ 


36-2 


1-20 


142-4 


0-01 


5 -5 j 1 -66 


184-1 


2-87 


1906 


24 ^^ 


15 


76-6 


— 


1*4 


16 


101-6 


0-30 



* Excluding re-admissions, the ratio is 21*6 per 1000. 

(1) Prevalence. — An examination of the figures in Table II shows 
that there were 13, 660 admissions for continued fevers, with 213 deaths 
•during the nine years, 1897 — 1905, and that these were made up as 
follows : — 



Simple continued fever ... 


t 
Admissions. . Per cent. 


10,665 

2,687 

408 


77 

20 

3 


Enteric fever 





The death-rate for the nine years' period works out at 1*20 per 1000 
for Mediterranean as compared with 1*66 for enteric fever. The 
percentage mortality to attack, in the case of Mediterranean Fever, was 
3*3 per cent., against a percentage mortality for enteric fever of 30*1 
per cent. A comparison of the Gibraltar figures for the corresponding 
period is of interest. They are as under : — 



Simple continued fever ... 
M^editerranean Ef^v^r 


Admissions. 


Percent. 


277 
107 
142 


62-6 
20-8 
27*1 


Enteric feyer 





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136 Major McCulloch, Major Weir, and Staff-Surgeon Clayton. 

The strength of Gibraltar was over half that of Malta. The death- 
rate for Mediterranean Fever was only 0*07 per 1000, against 0*87 for 
enteric fever. For Mediterranean Fever the percentage mortality to 
attack was 2*9 per cent., and for enteric 26 per cent. It is curious to 
note that the proportion which Mediterranean Fever forms of the 
total continued fevers is practically the same as for Malta, and that 
the percentage mortality to attack is very similar for both. 

(2) The Relation of Simple Continued Fevers. — The great prevalence 
in Malta of those indefinite forms of fever to which the designation 
" simple continued " has been applied is a very remarkable fact. We 
have seen that they constituted 77 per cent, of the total admissions for 
continued fevers diuing the nine years 1897 to 1905. Mild febrile 
attacks, dependent on a variety of causes, are of common occurrence 
amongst soldiers serving in hot countries, but Malta compares most 
unfavourably in this respect with every other garrison in which the 
British soldier is serving. The following table gives the comparative 
figures for the nine years 1897 to 1905, in the places named, which are 
given in order of prevalence : — 

Table III. — Simple Continued Fevers. 



Malta 

Egypt 

Straits Settlements 

Barbados (including St. Lucia).... 

India 

Jamaica 

Cejlon 

Bermuda 

South Africa — 

Four years before war, 1895-98 
Fouryears after war, 1902-05 . 

Hong Kong 

Mauritius 

West Coast of Africa 

United Kingdom 



Total admissions, 


Balios per 1000 


1897—1905. 


of strength. 


10,665 


142-4 


2,471 


64-6 


574 


62-2 


846 


48-2 


17,988 


80-5 


162 


29-9 


871 


27-8 


258 


15-7 


1,099 


46-9 


809 


6-5 


17 


1-8 


5 


0-7 


None 





1,798 


1-9 



Apart from the great prevalence in Malta of these ** pyrexias 
of uncertain origin," as they are to be designated in the new 
'* Nomenclature of Diseases/' their undue prevalence has a direct 
relation to Mediterranean Fever. Many cases are admitted to 
hospital for simple continued fever in which the diagnosis has to be 
changed later to that of Mediterranean Fever. For example, in 
1905, this happened in 100 instances. Over and over again, during 
our. investigation of cases in 1906, the question of ascertaining the 



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Epidemiological Worh in 1906. 137 

exact period of onset of a case of Mediterranean Fever was rendered 
difficult, and sometimes impossible, by a history of a recent, or even a 
remote, previous febrile attack. A not uncommon type of case is for a 
man to be admitted for fever, but giving no serum reaction, and after 
a stay of a week or a fortnight in hospital he is discharged to duty as 
a case of simple continued fever. A week, or a fortnight, or a month 
later, he is again admitted with febrile symptoms, and often with a 
history of not having felt well or of having had rheumatic-like pains for 
either the whole or part of the interval. This time his blood is found 
to react, and the illness pursues the ordinary course of a case of 
Mediterranean Fever. Sometimes an attack may be preceded by twa 
or more of these simple continued fever admissions. Or, again, there 
may be a history of a previous attack of fever, sometimes months 
before, and which may have caused a much longer stay in hospital than 
in the first type of case, but the clinical aspect was indefinite, and na 
serum reaction was obtained, and, consequently, the diagnosis of simple 
continued fever had to be made. On his second admission, the clinical 
appearances are unmistakable, the blood is found to give a typical 
reaction, and the case is returned as Mediterranean Fever. In some of 
these cases there is sometimes a connecting link between the 
admissions, in the shape of a history of the patient not having felt 
well since he was discharged from hospital after his first admission, or 
of having been more or less severely troubled by the rheumatic-like 
pains, which are so characteristic as sequelae of an attack of 
Mediterranean Fever. The history in these cases leaves little doubt 
in the mind, that the second fever attack is a relapse rather than 
a first infection, and that the first admission, when simple continued 
fever was diagnosed, was the beginning of the patient's Mediterranean 
Fever. There can be little doubt, therefore, that many cases which 
have been returned as simple continued fever are in reality mild cases 
of Mediterranean Fever. This must necessarily continue to be the 
case as long as there is no certain means of extinguishing between 
these atypical cases and ordinary febrile attacks. 

It will be seen from the following table that a considerable 
proportion of simple continued fever cases had a prolonged stay in 
hospital. 



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138. Major McCulloch, Major Weir, and Staflf-Sui-geon Clayton. 

Table IV. — Classification of Cases of Simple Continued Fever, admitted 
to the several military hospitals in Malta, according to the number 
of days imder treatment, for the years 1902 — 1905. The figures 
for 1906 are added for comparison. 



Year. 


Total 
number 
of cases. 


5 days 
under. 


5 to 10 
days. 


10 to 15 
days. 


15 to 20 
days. 


Over 
20 days. 


1902 
1908 
1904 
1906 

Totab 
1902-1906 

Percentages ... 

1906 


981 

781 

1360 

1199 


95 

79 

194 

223 


646 
457 
867 
676 


136 
142 
184 
189 


28 
62 
49 
50 


77 
61 
56 
61 


J43n 
604 


691 

13-7 
124 


2646 

61-4 
311 


660 

15 1 
43 


179 

4 1 
11 


246 

57 
16 



It will be observed that, roughly speaking, 75 per cent, of the 431 1 
cases of simple continued fever admitted during the four years 
1902 — 05 were cases requiring only a short stay in hospital, while 
25 per cent, were cases of severer type, and 5*7 per cent, required over 
20 days' hospital treatment. We have no exact knowledge as to the 
nature of the fevers represented in the last three of the five groups ; 
many of them may have been mild or atypical Mediterranean Fever 
cases. 

This Table also indicates that there was a large reduction in the 
prevalence of simple continued fevers in 1906, and especially in the 
10 to 15 days, 15 to 20 days, and over 20 days, groups. 

Another point which should not be lost sight of is the part which 
the ordinary febrile attacks may play in predisposing to attack by the 
severer diseases, Mediterranean and enteric. 

Simple continued fevers exhibit a very decided, it might almost be 
called an abrupt, seasonal prevalence. A sudden increase occurs in 
June, prevalence reaches its highest point regularly in July, decrease 
commences in August, and a drop almost as sudden as the rise in June 
is observed with the close of September. Chart 2 (p. 140) shows the 
average monthly prevalence of simple continued fevers for the seven 
years 1899 to 1905, together with the average temperature and rainfall 
curves for the same period. 

High prevalence of Mediterranean Fever in a unit is generally asso- 
ciated with high prevalence of simple continued fever cases, but a unit 
may have an unusual number of simple continued fever cases without 
any corresponding prevalence of Mediterranean Fever. The first hot 



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Epidemioloijicid Work in 1906. 139 

season that a regiment spends in Malta is usually marked by a high 
proportion of simple continued fever cases, and if it arrives close to the 
hot weather, or after the heat has set in, the greater is likely to be the 
prevalence of febrile attacks. 

The barracks in which simple continued fevers have been most 
eommon in recent years have been as follows: — In 1902, Manoel, 
Cottonera Lines, and Lower St. Elmo barracks showed greatest pre- 
valence. In 1903, Floriana barracks had most cases, and simple 
continued fever prevalence was associated with a very large outbreak 
of Mediterranean Fever affecting the 1st Battalion King's Royal Eifles. 
In 1904 a very great prevalence of simple continued fevers was asso- 
ciated with prevalence of both Mediterranean and enteric fevers in the 
2nd Battalion Essex Eegiment, which arrived in Malta from England 
on April 28, just at the beginning of the fever season, and were 
quartered in Lower St. Elmo Barracks ; next in order of simple con- 
tinued fever prevalence came Floriana, Verdala, Cottonera Lines, and 
Manoel, in all of which there was also a moderate prevalence of Mediter- 
ranean Fever, and in the three first-named barracks the occupants were 
newly-arrived regiments. In 1905 the greatest prevalence occurred in 
Lower St. Elmo, Cottonera Lines, Floriana, and Pembroke barracks, asso- 
ciated in all instances with marked prevalence of Mediterranean Fever. 
In 1906 Floriana was the barracks in which most cases were observed, and 
here, again, it was associated with prevalence of Mediterranean Fever. 
These facts would appear to indicate that simple continued fevers have 
a decided preference for the conditions obtaining in the old barracks, 
which are mostly in confined situations, and where, if overcrowding 
does occur, it is likely to have its worst effects. The preventive 
measure indicated is to spread out the men as much as possible in these 
old barracks during the hot weather months. 

Much work still appears to be required in the direction of still further 
separating simple continued fevers into component parts — (1) in con- 
nection with the ordinary febriculse, and (2) in connection with 
atypical cases of Mediterranean and enteric fevers, paratyphoid 
infections, etc. 

To sum up, then, the follo\ving considerations appear to warrant the 
l)elief that a close relationship exists between many cases of simple 
continued fever and Mediterranean Fever, and that the bond is a common 
causative factor or factors. 

1. The undue prevalence of simple continued fever in Malta as 
compared with garrisons in other warm climates. 

2. The constant association of Mediterranean and simple continued 
fever prevalence. 

3. The simultaneous disappearance of Mediterranean and simple 
continued fevers which has occurred in Gibraltar in the course of the 
last 20 years. 



Digitized by VjOOQ IC 



140 Major McCulloch, Major Weir, and Staft-Surgeon Clayton 

Monthly prcvaJcnoe — Ratios per ipoo of strength. 
1899 to 1905. 

JAn. Feb. Mat Apr Meuj June July Au^ Sept. Oct. Nov. Dec. 



450 



400 



350 



300 



250 



200 



150 



100 



50 



fl 



n 



fl 



21-4 IW 26^ 3x1 46* Z43-8 4M-3 303rl 271*8 34-8 
Ratios per 1^00 



i 



Ji 



19-6 



Means 
Temperature and Rainfall 1899 to 1905 




Chart 2. — Simple continued fever amongst tlie troops in Maltai 



Digitized by VjOOQ IC 



Epidemiological Work n 1906, 

prevAlence — Radios per ipoo 
1906. 

Jan. Febi M&r. Apr. Ma>j June July Aug: SepC. Oct. Nov. Dec. 



141 



Monthly prevAJence — Ratios per ipoo of strength. 
1906. 



-400 



.550 



:300 



250 



:2O0- 



150 



JIOO 



50 



XL 



n 



II 



XL 



7-4 3-2 3-0 6-5 I6-5 215-4 33I-4 II*-« 120-0 58-6 32»4 M 
'Ratios per ipoo 



Temperditure and RAinfa.ll 1906. 




Chart 2. — Simple oontinued feyer amongst the troops in Malta. 

Digitized by VjOOQ IC 



142 Major McCulloch, Major Weir, and Staff-Surgeon Clayton. 

4. A similar reduction of simple continued fever prevalence has 
occurred during the second half of 1906 in Malta, in connection with 
a reduction of Mediterranean Fever p^e^-alence. This will be referred 
to further in a later part of the Reix)rt. It is well shown in Chart 2 
(p. HI). 

(3) The Belation of Enteric Fever. — It is not uncommon to find Mediter- 
ranean, enteric, and simple continued fevers all prevalent at the same 
time and in the same areas. For example, the fever prevalence in the 
Essex Regiment in 1904 and 1905 was of this kind. 



2nd Battalion Essex Regiment (arrived in Malta, April 28, 1904). 



Montb. 



Mediterranean I Simple continued 
Ferer. fever. 



Enteric feyer. 



1904^ 

May 

June 

July 

August ... 

September 

October ... 

November 

Deoemb e 
1905— 

January ... 

February... 

March 

April 

May 

June 

July 

August ... 

September 

October ... 

KoTcmber 

December 



/ 

19 

20 

18 

7 

7 

1 



8 

6 

19 

19 

18 

18 

9 

9 

4 

2 



67 

226 

86 

44 

4 
2 
3 

1 

1 

9 

7 

88 

46 

20 

14 

1 

1 



It will be observed that enteric was the first of the continued tevers 
to make its appearance among the men of this regiment, and that it 
began immediately on their arrival, but was most prevalent during the 
four months October to January, a period which had been preceded by 
a large outbreak of simple continued and Mediterranean fevers, and 
just as these fevers were beginning to show subsidence. Another 
example is a sharp outbreak of Mediterranean and enteric fevers which 
occurred in 1899, simultaneously, amongst the civil population of 
Rabato and the troops at Imtarfa barracks. 

The following facts appear to show the existence of some relation 
between the two diseases, but it is a relation regarding which there 
is no very precise knowledge. 



Digitized by VjOOQ IC 



Epidemiological Work in 1906. 



14* 



The Micrococcm inelitensis and J?, 
from the same case post mortem, 

1899 Co 1905 



IS have both been recovered 





Jan. 


Feb. 


Mar. 


Apr. 


Maa 


June 


July 


Aug. 


Sept. 


Ocb. 


Nov. 


Dec. 


20 


























10 


n 


n 


n 


n 


n 





- 








1-1 


— 








ri 



yi M 4-9 i-4 1-8 3'6 IO-3 8*7 49 5^0 6^2 ?! 

1906 



20 



zo 



Ja-n. 


Feb. 


Mar 


Apr. 


May 


June 


Juit) 


Aug. 


SepC. 


Oct. 


Nov. 


Dec. 


















































n 


















n 










4Hr 


» 


— 


4 


5 


6 


Z 


— 


— 


1-6 


— 


— 







Chart 8. — Enteric fever amongst the troops in Malta. — Montlilj preTalenoe. — 

Ratio per 1000. 

In doing blood reactions in fever cases, the serum is not infrequently 
found to cause clumping of both Micrococcus melitensis and B. typhoms. 
We have a record of 74 instances of this occurring among the cases 
coming under observation in 1905 and 1906. In 24 of these instances 
there was a good reaction to both Mediterranean and enteric ; in one 
instance only was the enteric reaction the more pronounced, and in the 
remainder the Micrococcus melitensis agglutination predominated. There 
is no reason why the two diseases should not be drawn from sources 
existing quite separately at the same time and in the same areas, but 
the frequent occurrence of cases presenting these double reactions seems 
curious. 



Digitized by VjOOQ IC 



144 Major McCuUoch, Major Weir, and Staff-Surgeon Clayton. 

Mediterranean Fever often supervenes on enteric, but in most such 
■cases the possibility of a fresh infection having occurred presents 
itself. 

There has been a complete absence of enteric fever in the garrison 
<Juring the second half of 1906 (vide Chart 3), which is the part of the 
year when enteric usually prevails, and this corresponds in point of 
time with a considerable lessening in the ordinary prevalence of both 
Mediterranean and simple continued fevers. 

(4) Prevalence of Mediten-mmn fevpr in Malt<ifrom 1897 to 1905. — 
Table II (p. 134) shows that from the beginning of 1897 to the end of 
1905 Mediterranean Fever caused 2687 admissions to hospital amongst 
the non-commissioned officers and men of the garrison, and there were 
89 deaths. During the same period there were also 241 cases with 
three deaths amongst the officers, 310 cases with 20 deaths amongst 
soldiers' wives, and 145 cases with two deaths amongst soldiers' 
children. The total number of admissions in the garrison during the 
nine years was, therefore, 3383, and the total number of deaths 115, 
which figures give an admission ratio of 38*0 per 1000, and a death 
rate of 1*29. Invaliding from Malta on account of Mediterranean 
Fever is high, and must be a source of large expense to the State, as in 
the nine years under consideration it caused the invaliding of 128 
officers and 1137 men. 

Year after year, with unfailing regularity, Mediterranean Fever has 
manif ^ted a widespread prevalence amongst the troops, cases being con- 
tributed each year by practically every corps, and a scattered distribu- 
tion in barracks being the usual rule. In some years the distribution has 
been a general one, while in others the prevalence has been epidemic 
in character. An important feature of epidemic years is that the 
putbriak is usually confined to single, or sometimes one or two, units, 
Uhile nothing more than ordinary prevalence is observed amongst the 
rest of the garrison ; 1898, 1905, and 1902 may be taken as examples 
of years showing fever prevalence of a generally distributed character, 
but at the same time they are years of marked contrast in reganl 
to the extent of prevalence and the forms of fever prevailing. 

In 1898 very high fever prevalence was observed, the ratio for all 
continued fevers, 2396 per 1000, being the highest recorded since 
1859, but the excessive prevalence was chiefly in cases of simple 
continued fever, the admission rate for Mediterranean Fever bein^ 
below the average for the nine years' period. The year which comes 
next in regard to high fever prevalence was 1905, with a total ratio of 
229-6 per 1000, but in this year the ratio of 77*5 for Mediterranean 
Fever is the highest on record; the ratio for the simple continued 
fever cases was just above the average, as was also the admission rate 
for enteric fever. In 1902, although there was a large garrison, fever 
prevalence was at the lowest point observed in the nine years under 



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Epidemiological Work in 190j5. 145 

consideration, the Mediterranean Fever rate being the very low one of 
17*7 per 1000, while the admission rates for both simple continued and 
enteric fevers were also below the average. , .. 

The years 1899, 1903, and 1904 present good examples of localialed 
epidemic prevalence of Mediterranean Fever. The outbreak in the 
Essex fiegiment in 1904 has been very fully described by Dr, Johqsto^e 
in Part II of these Eeports. The outbreaks in 1899 and 1903 
present points of epidemiological interest which seem worth putting qq 
record. 

In 1899, a sharp outbreak of Mediterranean and enteric fevers 
occurred amongst the civil population of Babato, a suburb of Citta 
Vecchia, and about three-quarters of a mile distant from Imtarfa 
Barracks. At the same time both diseases made their appearai^ce 
amongst the troops at Imtarfa, most of the cases being Mediterranean 
Fever. The epidemic lasted three months, May to July. The civil 
and military authorities joined hands in an endeavour to trace the 
source of (he disease, without result. The points of interest are: 
(1) The sudden onset of the outbreak ; (2) the simultaneous invasion 
of both military and civil sections of the population ; (3) the time of 
year, which was rather early for an outbreak, as Mediterranean Fever 
is usually most prevalent from June to September, and the last 
six months of the year is the period of seasonal prevalence for enteric. 
The simultaneous invasion indicates a common factor, or factors, tlie 
barracks are situated in an isolated position, on a hill at some distance 
from Babato. There was no reason to suspect the water supply, as no- 
local source of pollution could be discovered, and it was common to- 
other places which were not attacked. The barracks were only opeined 
in 1896, and their sanitary condition should, therefore, have been 
satisfactory, and we are told that nothing was discovered to which the 
cause of the outbreak could be attributed. The only food supply 
common to both civil and military was milk, and although we are not . 
in a position to give a definite negative to all other probabilities, 
viewed in the light of our present knowledge, milk as the causative 
factor seems best to explain epidemic prevalence, sudden onset, siiaul- 
taneous invasion, and early appearance. We know that Babato is. 
a place having many herds of goats, and that, in recent times, gjoatr 
there have yielded infected milk, and, by inference, therefore, possibly 
also in 1899. We know that milk from the goat often contains the 
Micrococcus melitensis in enormous numbers, but that the quantities 
present in the milk show great variations from time to time, that they 
may disappear for days and reappear later, and that no obyious 
relation has been observed to temperature or to season of the year, 
either in regard to abnormal presence of Micrococcus melilensis, ok* ta 
their disappearance altogether from an infected milk. ' 

In 1903, a very large outbreak occurred in the Ist BattaUon 
(2089) / 



Digitized by VjOOQ IC 



146 Major McCulloch, Major Weir, and StafiF-Surgeon Clayton. 

King's Royal Rifles. The regiment arrived in Malta from South 
Africa on October 16, 1902, and were quartered in Floriana barracks 
until the end of April, 1904, when they moved to Imtarfa barracks, 
where they remained until they left for Egypt on February 27, 1905. 
Major Glenn Allen, R.A.M.C., who was in charge of Floriana District 
at the time of the outbreak, states,* that the battalion contained 
a fair proportion of seasoned men on its first arrival, but during the 
first winter its strength was increased, and the places of old soldiers 
sent home, time expired, were filled by the arrival of two or three 
drafts from the dep6t. So that by the time the warm weather began 
there were a good many young soldiers in the ranks who, by reason of 
their immaturity, may reasonably have been considered as specially 
liable to infection. 

The following table gives a complete view of the fever prevalence 
during the entire time of the stay of the battalion in Malta : — 



Month. 


Mediterranean 
Fever. 


Simple continued 
fever. 


Enteric fever. 


1902— 
October 


8 
8 

6 
18 
47 
61 
45 
19 
13 

7 
1 
6 
2 
7 
4 
4 
3 
4 

1 
1 

2 

1 


2 
2 

1 

1 

1 

2 

1 

1 

18 

88 

71 

9 
8 

1 

2 
3 


1 
1 

""" 
1 

1 

1 
1 
1 

1 


NoTember 

December 

1908— 
January 


Fflbmary 


March 


April 


May 


iTunft 


July 


Anmist 


September 

October 


November 

December 

1904— 
January 


February 


March 


April 


May 


June 


July 




SejH^mber 

October 


November 

December 

1906— 
tl anuary . t 1 1 - t - 1 


February 





* ' Journal of the Boyal Army Medical Corps ' for June, 1904. 



Digitized by VjOOQ IC 



Epidemiological Work in 1906. 147 

During 1903 there were in all 209 admissions for Mediterranean 
Fever, with five deaths, and 65 men had to be invalided. The special 
prevalence of the disease began in June, and the epidemic was at its 
height in August, September, and October. It will be observed from 
the monthly figures, given above, that the epidemic prevalence of 
Mediterranean Fever cases was preceded by epidemic prevalence of 
simple continued fevers, and that there had been admissions for simple 
continued fever from the very first month of the arrival of the 
battalion in Malta. It is interesting also to note the almost entire 
disappearance of simple continued fevers that marked the last 
14 months of the stay of the regiment in Malta. In August and 
September, cases of Mediterranean Fever were also observed amongst 
the women and children of the regiment who were living in quite new 
married quarters, A Block, Misida Bastion. The enquiries made at 
the time of the outbreak appear to have been negative in their result, 
except that it was held that '^ insanitary conditions" would not 
explain its occurrence, and the tendency was to accept the theory of 
air-borne infection. Building operations were going on in the vicinity, 
and there had been much digging and turning over of the soil, but, 
as Major Glenn Allen points out, " By the time the fever made its 
appearance among the single men the new blocks of barracks were 
practically completed. The disturbance of the soil, involved in digging 
the foundations, had taken place during the time that another battalion 
was stationed in the Floriana District, among whom no exceptional 
number of cases had occurred." Nor was there any special prevalence 
of these fevers in the old married quarters, which are between the new 
blocks and the buildings occupied by the troops in Old Floriana barracks. 
As no conveniences are usually provided for the Maltese workmen 
employed on new buildings, the theory has recently been advanced that 
the soil becomes extensively polluted, and that the presence of one or more 
ambulatory cases among the workmen might be sufficient to sow the 
seeds of the disease. It has to be remembered, however, that infected 
urine does not usually contain the specific micrococci in large numbers, 
consequently very gross contamination of dust should not often occur. 
The fact also that the Micrococcus melUensis is readily destroyed by 
exposure to sunlight, and the rapid dilution that must occur when the 
dust is blowing about under natural conditions, are against dust being 
a very common factor. Dust-borne infection might be operative in 
causing a few cases, but, all things considered, it would not explain an 
epidemic, occurring in the hottest months of the year, and of the 
extent of the one under consideration. The only fresh fact we can 
give in connection with this outbreak is that the regimental milk 
supply was goats' milk. The supplier informed one of us this year 
(1906) that he and his forebears had supplied Floriana barracks with 
goats' milk for the last 20 years. In April, 1904, the battalion was 
(2089) I 2 

Digitized by VjOOQ IC 



148 Major McCulloch, Major Weir, and Staflf-Surgeon Clayton. 

moved to Imtarfa, where there was no excessive prevalence of Mediter- 
ranean Fever, and several of the cases recorded as admissions were 
relapses from the previous year. After arrival in Egypt on March 4, 
1905, the battalion was stationed at Cairo, where there were five 
admissions for Mediterranean Fever during that year. All of them 
were men who had been with the regiment in Malta, but only one of 
the five is known to have had fever there. The admissions were as 
follows : — 



1 


Date of 
admission. 


Date of 
discharge. 


Interval since 
leaving Malta. 


H. 5968 PriTste J 


9/6/06 

8/8/05 

8/8/05 

17/8/05 

16/8/06 


9/10/06 
(invalided) 
25/9/05 
28/9/05 
28/9/05 
28/9/05 


days. 
70 

161 
161 
170 
169 


H. 2578 Lanoe-Oorpond J»... 
H. 4736 Private H 


G. 2589 „ L 

H. 4557 BoyS 



• Had Mediterranean Fever in Malta, 9/9/03—29/11/03. 

The diagnosis in all five cases was confirmed by serum reaction. 
The interval between leaving Malta and the onset of illness is a long 
one in each case, and suggests fresh infection, but no men who had 
not been in Malta were attacked. The grouping of the cases, four 
men belonging to one company, and the closeness of the dates of the 
August admissions, suggest contact as a factor, especially as the 
second of the cases had had Malta fever previously, but the case for 
contact would have been better, had some man or men been attacked 
who had not been in Malta. It is also an open question as to whether 
the lance-corporal's case should be regarded as a relapse, after an 
interval of just over two years, or as a fresh infection. The milk 
supply of the battalion in Cairo was tinned milk, but the men might 
have had access to goats' milk outside barracks. 

With reference to the epidemic and the prevalence of fevers 
generally in the battalion while in Malta, the epidemiological points 
which are of special interest are : — 

(1) A large epidemic which was at its height from August to 
October. In 1899, epidemic prevalence occurred at Imtarfa during 
the three months May to July. This appears to indicate a factor 
outside seasonal prevalence. 

(2) The epidemic prevalence of simple continued fevers, which 
preceded, and was associated with, the Mediterranean Fever outbreak. 

(3) The remarkable absence of simple continued fevers which 
marked the hot weather of 1904, and which may have been the result 



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Epidemiological Work in 1906. 149 

of the move of the regiment from the old barracks at Floriana to the 
new barracks at Imtarfa. 

Prevalence in Barracks, — Floriana barracks are several times brought 
to notice for high fever prevalence during the period 1861 to 1897, 
but as to the exact character of the fever prevailing in such years 
no information is available. Simple continued fevers, no doubt, 
formed the bulk of the admissions, but simple continued fever is not 
as a rule a fatal disease, so that, as death rates were observed, the more 
severe types of fever, t.e., Mediterranean and enteric, must ako have 
been present. In the majority of the years of this period, Floriana 
does not rise above the average, and in some, notably 1864, 1865, 
1867, and 1889, it is remarkable as having had a low fever prevalence. 
Since the years of separate fever statistics, Floriana occupied 
a prominent position, in regard to Mediterranean Fever prevalence, in 
1897, and in 1903 there was a large epidemic; prevalence, rather 
above the average, was observed in 1904 and 1905, and considerably 
above the average in 1906 ; while 1898, 1899, and 1901 were years of 
very moderate prevalence; and 1900 and 1902 were years in which 
these barracks had a low prevalence of Mediterranean Fever. 

Kicasoli, Yerdala, Isola Qate, and Polverista barracks have each 
attracted special attention at different times, both for high and for 
low fever prevalence. Since 1897, Kicasoli has never shown more 
than low figures for Mediterranean Fever, although there were more 
cases than usual in 1905. Yerdala barracks have maintained a fair 
reputation for moderate Mediterranean Fever prevalence in the years 
1898 to 1906. Yerdala has bad at times a high admission rate for 
dimple continued fevers, and it has had an enteric notoriety in the past. 

Lower St. Elmo, which in 1859 was regarded as one of the most 
unhealthy barracks in Malta, was specially mentioned for low sickness 
rates in 1861, 1862, 1864, 1865, 1871, 1872, and 1889. In the Army 
Medical Department Report for 1872 it is stated that ''Lower 
St. Elmo maintains its good character." But it occupied the highest 
place for fever prevalence in 1875 and again in 1883, while it had the 
second highest place in 1892. These barracks have had an enteric 
reputation in years past. As far as Mediterranean Fever is concerned, 
they have a fair repute from 1897 to 1903, but in both 1904 and 
1905 they headed the list for Mediterranean Fever prevalence, while 
in 1898 and again in 1902 low prevalence was observed. 

Manoel barracks have never shown more than moderate prevalence 
up to 1905, when each contributed about ^ye times its average number 
of cases. 

St. Qeorge's barracks, Pembroke, have usually shown moderate 
prevalence, but here, too, there was a considerable increase in 1905. 

Even the newest, well built and well sited barracks are not exempt, 
as Imtarfa barracks, which are situated on a hill in the open country, 



Digitized by VjOOQ IC 



150 Major McCulloch, Major Weir, and StafiT-Surgeon Clayton. 

began to show fever prevalence in 1896, the year they were opened ; 
a sharp outbreak of Mediterranean Fever occurred in them in 1899 ; 
and they again showed more than ordinary prevalence in 1905. Tigne 
(stone barracks), opened in 1901, the new blocks at Floriana, opened in 
1903, and St. Andrews barracks, opened in May, 1905, have all 
contributed cases of Mediterranean Fever. The same is true of both 
old and new married quarters. The provision of new buildings with 
sanitary fittings and general surroundings far in advance of those 
of remote periods has not prevented the occurrence of Mediterranean 
Fever amongst the occupants. 

The foregoing considerations show that great irregularity is 
manifested from year to year in regard to the extent of fever 
prevalence in the various barracks in Malta. There is no evidence of 
a persistent and constantly recurring place infection in connection 
with any of the barracks, except perhaps in Floriana old barracks, 
which, since the large epidemic of 1903, appears to have contributed 
more than its normal share of cases of Mediterranean Fever in 1904 
and 1906, but it was better than Lower St Elmo in 1905. 

3. Prevalence of Mediterranean Fever in Different Branches of the 

Service, 

The following table shows the prevalence of Mediterranean 
Fever in Malta, by branches of the service, during the foiu* years 1902 
to 1905. 

(1) Artillery and Infamiry Compared, — This table shows that the 
artillery have suffered less from Mediterranean Fever than the 
infantry, the ratio for the former being 28*0 against 47*2 per 1000 for 
the latter. The general sickness rate amongst artillery is generally 
better than the infantry, but this, it is thought, would be insufficient 
to account for the large difference in prevalence of Mediterranean 
Fever. One very important difference between the two bodies of men 
is that the artillery generally have used condensed milk, while the 
infantry have used goats' milk. We are not absolutely certain about 
the milk supply of some of the artillery units that left Malta during 
the early part of the four years' period, but on the assumption that 
they used goats' milk in place of condensed milk, it would only make 
the difference in the rates the more striking. 

(2) Special Prevalence of Mediterranea/n Fever in tlte Royal Army 
Medical Corps, — This is obviously an important point, more particularly 
as a similar special liability is observed among the Sick Berth Staff of 
the naval hospital at Bighi. 

Table V, p. 151, shows that during the four years 1902 to 1905 the 
incidence rate for the Eoyal Army Medical Corps is three times the 
infantry rate, 148 as compared with 47*2 per 1000. The general 



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Epidemiological Work in 1906. 



151 



1 

if 

r 



H 






I 

I 



i 

I 






•^ 



^1 



r« 06 09 ^ 

CD M 06 IP 

»H oi t^ 25 



^ 5P 9 

^ ^ CO 



g 3 S S S 



9 CO «> 9 ^ I 

00 CO "^ lO to 



kO 



s 



^1 



I 



^ 3 



^ 

s 



I-* CO •* 



•* N 9 



J5 O •* CO iH QO 

ud Ob *H t^ ko 



ll S S 2 8 S 



n 



CO 9 

3 9 



09 






•I- 

o 



g 3 g I ^ 3 2 

»0^ OD^ 00^ iH »0 C^ W 






I 



-*1 

c 
o 

"S. Ill, 

H M ffi 



I 6 



!• a o 






J^ 



08 



Digitized by VjOOQ IC 



1 52 Major McCulloch, Major Weir, and Staff-Surgeon Clayton, 

admission rate from all causes for the Soyal Army Medical Corps 
usually conforms fairly closely to that of the infantry, but, in that 
year of special fever prevalence, 1905, the medical unit had a general 
admission ratio of 974*2 per 1000 against 681*8 for the infantry. It 
is also observed that continued fevers, using the designation in its 
inclusive sense, caused 50 per cent, of the total admissions to hospital 
from all causes among the Boyal Army Medical Corps, whereas in the 
garrison as a whole the proportion is about 21 per cent., and even 
that must be regarded as an excessive proportion. 

From the beginning of 1902 up to the end of September, 1906, the 
average annual strengths of the Soyal Army Medical Corps were 99 
in 1902, 140 in 1903, 143 in 1904, 155 in 1905, and 164 for January 
to September, 1906. The actual nrunber of non-commissioned officers 
and men who served in Malta during the period in question is 364, 
and of these three were there for the second time. Of the 364 men, 
92 contracted Mediterranean Fever, their service in Malta at the time 
of contraction being : — 



Under 
1 year. 


lto2 
years. 


2to8 

years. 


3to4 
years. 


4to6 
years. 


5 to 10 
years. 


Total. 


44 


24 


14 


6 2 


2 


92 



These figures demonstrate the special liability of the newcomer to 
attack by Mediterranean Fever. 

Including simple continued and enteric fevers with Mediterranean 
Fever, an. examination of the corps records in Malta showed that 
a considerable proportion of men escape fever altogether, and employ- 
ments which figure often in this group were wardmasters, compounders, 
clerks and men employed in stores. 

The following table gives the admissions for continued fevers during 
ihe four years 1902 to 1905. Of the 92 cases referred to above, five were 
men who had contracted the disease prior to 1902, and there were 
nine re-admissions, hence the total of 78 admissions for Mediterranean 
Fever shown in the table. 



Digitized by VjOOQ IC 



Epidemiological Work in 1906. 



153 



Eoyal' Army Medical Corps. 



Average 


Mediterranean ^^?P^® , 
Fever. . continued 
fever. 

• 


Enteric fever. 


Total 

continued 

fevers. 


lear. 


strength. 


Admis- ^**^ Admis- 


Batios 
per 
1000. 


Admis- 
sions. 


Batios 
per 
1000. 


Admis- 
sions. 


Batios 
per 
1000. 


1902 
1908 
1904 
1905 


99 
140 
143 
166 


8 
17 
19 
39 


30-3 
121-4 
132-9 
261-6 


16 
27 
27 
48 


161-6 
192-9 

188-8 
277-4 


1 

1 
1 


10 1 

7-0 
6-4 


20 

44 
47 
83 


202-0 
814-3 
828-7 
586-4 


78 


148 


118 


214-4 


8 


5-7 


194 


368 1 



During these four years 50 men of the Eoyal Army Medical Corps 
were invalided on account of Mediterranean Fever, and it caused two 
deaths, both in 1905. 

Next to the great prevalence of fevers in 1905, the marked 
disparity between 1902 and the following years, as regards fever 
prevalence, is the point which shows up most prominently in this 
table. The most probable explanation of this is absence of the usual 
arrival of susceptible material, owing to the fewness of reliefs during 
the South African War years, 1899 to 1902. That there were very 
few fresh arrivals to join the corps at this period is well shown in the 
following analysis of the composition of the Eoyal Army Medical 
Corps unit serving in Malta at the beginning of 1902. It was 
composed of men who had joined as under : — 



1896. 



1897. 



1898. 



19 



63 



1899. 



1900. 



1901. 



10 



In 1902, 77 men joined the station, six of them between February 
and August, 70 on October 14, and one in November. With the 
accession of this fresh material, Mediterranean Fever began after 
a brief interval. There were only three admissions for the disease in 
1902. The first was a man who had joined in January, 1901, and 
who was admitted on January 24, 1902. The next was the case of 
a man who, within a month of his arrival on May 21, 1902, was 
admitted for simple continued fever, and was almost continuously ill 
afterwards, until invalided on March 10, 1903 ; no blood reaction was 
obtained in this case until October 8, 1902. The third was a man of 
the large draft which arrived on October 14, who was admitted for 
Mediterranean Fever on December 19. The subsequent history of 



Digitized by VjOOQIC 



154 Major McCulloch, Major Weir, and Staff-Surgeon Clayton. 

this draft is as follows : eight of the men wdre admitted for the disease 
in 1903, eight more in 1904, four in 1905, and three in 1906, 24 cases 
in all out of 70 men. 

The distribution of the disease in the detachments serving in the 
various military hospitals during the four years was as follows : — 

Hospitals. 





Valletta. 


Cottonera. 


Forrest, y^^^j^ 


Imtarfa. 


Goto. 


1902 


3 (60^ 

4 (222) 
10 (167) 
20 (300) 


- (52) 

8 (66) 
6 (62) 

9 (143) 


— (12) — ns^ — (is\ 1 — (s.'i 


1908 

1904 

1905 


— (82) 
2 (93) 


1 (70) - (14) - (OJ 
1 (22) — (28) - (14) 
3 (32) 1 (69) |- (6) 


Total 


87 (749) 
ll54-l 


23 (823) 
149-8 


8 (164) 
76-9 


5 (189) 1 ^124^ 


- (28) 


Admissions, 

ratio per 1000 

of oorps strength, 

1902-05 


98-0 


32-2 



The figures within the brackets indicate the number of cases of 
Mediterranean Fever admitted during the year to each hospital. 
Cases were treated in each of these hospitals up to May, 1906, after 
which all cases of the disease were sent to Valletta. This table shows 
that there is no constant relation between the numbers of cases 
occurring among the sick attendants and the quantity of possibly 
infective material in the wards. For example, at Valletta in 1903 
there were four Royal Army Medical Corps cases with 222 admissions 
for the disease, while in 1905 there were 20 cases in a year which had 
300 admissions. At Cottonera in 1903 there were eight corps cases 
with 66 Mediterranean Fever cases, while in 1905 there were only 
nine when more than double the 1903 number of cases passed through 
the hospital. Compare also Civita Vecchia, one with 70 in 1903, and 
three in 1905, when there were but 32 admissions. 

The monthly distribution of cases was as under : — 







Royal Army Medical Corps 










Year. 


January. 
February. 


1 

:3 


April. 
May. 


June. 
July. 
August. 
September. 


1 


1 

1 


u 
J 


1902 


1 


_ 


_ 














1 




1 


1903 


1 


— 


1 


1 


2 


2 


1 


2 


1 


1 


2 


8 


1904 


1 


4 


1 


— 


1 


1 


2 


3 





2 


2 


2 


i 1905 


3 


— 


1 


2 


3 


4 


8 


10 


2 


2 


1 


3 


! 1906 


3 


8 


1 


3 


5 


1 


— 


2 


— 




— 


— 



Digitized by VjOOQ IC 



Epidemiological Work in 1906. 



155 



The monthly prevalence of the disease in the corps follows very 
much the same distribution as is exhibited by the rest of the garrison. 

OccupaHon. — The duties of the 69 men at the time they contracted 
the disease were as follows : — 



1902-08. 



Ward duty 

Cooking oIms ... 

CJooks 

Stewards* stores 
Compoonder ... 
Steward 

Total ... 



Men. 



2 
1 

1 



16 



1904—06. 



Ward duty {^"^■•^-••:;; 

Cooking class 

Cooks 

Clerks 

District staff 

Day ward master and stewards* 
stores 

Pack and linen store 

Steward 

Total 



Men. 

:?} 
1} 

3 
2 
1 

1 
1 

68 



Total. 

46 
12 



fFard Dviy, — Prior to 1904, all the men of the Eoyal Army Medical 
Corps employed on " ward duty " took more or less share in nursing 
the sick, but since 1904 these men have been divided into two 
classes, namely, a nursing section, the men belonging to which are 
specially charged with the nursing of the sick, and a general duty 
section, to the men of which falls the cleaning work of the wards. The 
nursing section man, therefore, comes into more intimate contact with 
patients than the general duty man ; but the latter, in times of special 
strain, may sometimes have to lend a hand in nursing, and often men 
belonging to the general duty section are working as probationers, wibh 
a view to passing into the nursing section. The general duty man 
employed in and about the Mediterranean Fever wards must necessarily 
handle possibly infected clothing and bedding, and may also come in 
contact with infected urine in latrine work. 

The evidence which tells most in support of contact as a factor in 
the causation of the special prevalence of the disease amongst the men 
of the corps in Malta is that given by Kennedy,* in which he shows 
that while both nursing section and general duty men employed in 
1905 in 20A ward, Valletta Hospital, the ward in which Mediterranean 
Fever cases were treated, contracted the disease, yet no attacks 
occurred amongst the men of either class who were employed in other 
wards, where there were no such cases. There are, however, some 
stumbling blocks in the way of general acceptance of the view that 
contact with cases is a factor of primary importance. There would 
appear to be no constant relation between the numbers of cases 

* * Journal of the Boyal Army Medical Corps ' for April, 1906. 



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156 Major McCuUoch, Major Weir, and Stafif-Surgeon ClaytoiL 

occurring amongst the sick attendants and the quantity of infective 
material in the wards, and the history of previous years does not 
always show that men doing ward duty are marked out by special 
liability to attack. For instance, it is observed, on analysis of the 
cases that occurred in 1903 amongst -the detachment at Ck>ttonera» that 
the employments of the eight men who contracted the disease were as 
follows : — Compounder, 1 ; in the steward's stores, 2 ; cooking class, 
3 ; and ward duty, 2 ; but one of the latter was employed in the itch 
tents, and the other was a lunatic attendant. Again, the nursing 
sisters do not show special liability to the disease in the performance 
of their nursing duties. There were six cases amongst the sisters at 
Cottonera in 1904 to 1905, but no cases of the disease have been 
observed amongst the nursing sisters at Valletta, although they have 
had to deal with more than double the number of cases of Mediter- 
ranean Fever during the four years under discussion. It is also 
important to note that contact with cases of the disease is not accom- 
panied by the occurrence of cases among the sick attendants on the 
hospital ship '' Maine " or in the home military and naval hospitals. 
No such cases have ever been observed, although there must be the 
same contact in nursing patients and the same handling of infected 
clothing, bedding, and excreta as in Malta, and probably with less 
attention to personal precautions than is observed in the case of the 
nursing staffs of the hospitals in Malta. These facts seem to com- 
pletely negative the view that "contact" is a factor of primary 
importance in the causation of the special prevalence which has been 
observed among the men of the Royal Army Medical Corps in Malta. 
The one great difference in the conditions between nursing cases of the 
disease in Malta and away from Malta is the complete absence of a 
specifically infected milk supply in the latter case, and its common 
presence, at all events in the past, in the former. 

Cooking, — The common occuiTcnce of cases of the disease amongst 
men employed in cooking in military hospitals in Malta is a significant 
fact, and one in which infection by milk is strongly suggested, as these 
men had the handling of milk before its sterilisation. Cases of this 
kind seem to have been of particularly common occurrence at Cottonera 
in the past. 

Superintendence of Goat MilJcing. — Three cases have been observed in 
which this formed part of the duties of the men attacked. 

Handling Infective Material. — Three out of four men belonging to the 
£oyal Army Medical Corps who have been employed in the Commission 
laboratory have been attacked by Mediterranean Fever, one in 1905 
and two in 1906. In their case the probabilities are strongly in favour 
of the disease having been contracted by the handling of infective 
material. It is also possible that infection sometimes occurs from 
handling infected clothing, bedding, excreta, etc. 



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£pidemiological Work in 1906. 



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158 Major McCulloch, Major Weir, and Stafif-Surgeon Clayton. 

It is very significant that since tbe milk change, that is to say, durii\ 
the last six months of 1906, there have been but two cases, both a 
Valletta, and both inoculated men. One was a laboratory attendant 
and the other is a possible relapse. (See Cases 17 and 18, Series II, 
the cases in the Royal Army Medical Corps, p. 194, where the cases 
occurring in 1906 are discussed in detail.) 

The foregoing table indicates : — 

1. That no unit escapes attack by Mediterranean Fever. 

2. That an interval always elapses between the arrival of a unit in 
Malta and the first appearance of Mediterranean Fever. That is to 
say, the sufierers have to come to Malta to contract the disease, they 
are not landed suffering from it. 

3. That, in the infantry, the interval has varied from under 3 weeks 
to, in one instance only, 4^ months (units whose milk supply is usually 
goats' milk). 

4. That, in the artillery, the interval is often much lengthened, 
varying from 3 weeks to 4^, 5^, 7, 8^, and 15^ months (units whose 
milk supply is condensed milk). It will be observed that many of the 
artillery companies are moved on from Gibraltar to Malta, and it might 
be urged that the susceptible men have been exhausted during the 
service of the company in the former station, but exhaustion of 
material will not explain the point, as there has been very little 
Mediterranean Fever amongst the troops in Gibraltar during the years 
in question. 

5. That simple continued fevers nearly always appear first, and that 
enteric fever is generally later in showing itself than either Mediter- 
ranean or simple continued fevers. 

(4) Prevalence amongst Officers, WomeUy a/nd Children, — Table VII gives 
the Mediterranean Fever statistics relating to officers, women, and 
children for the nine years 1897 to 1905. The figures for the N.C.O.'s 
and men are added, to give a complete view of the prevalence of 
this fever in the garrison throughout the period in which separate 
statistics become available. 

It has been divided into separate periods, because during the second 
period the serum reaction, as an aid to diagnosis, was in routine use 
throughout, but this was not the case in the first four years, 1897 to 
1900. Blood examinations in cases suspected to be Mediterranean 
Fever were carried out by individual medical officers from about 1899, 
but an order was published on November 6, 1900, directing that these 
examinations were to be made in all cases. The figures relating to the 
second period are, therefore, the more complete, and that is why the 
following remarks are confined to that period. 

On making an analysis of the statistics relating to the garrison as a 
whole, it was found that, in proportion to strength, the liability of the 
officer to be attacked by Mediterranean Fever is over three times as 



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{To fact p. 158.) 



Children. 






Totalfl. 










Batios per 


JZ 






Batios per 






1000. 


1 


S 


« 


1000. 


1 1 


.S g 


1 


B § 
^•3 


eaths. 


1 ® 


-< ^ 


^ 


^ 


^ 


^ I 


11 1 


8-1 


1-35 


9,454 


309 


15 


1 
32 7 1 1 -58 ' 


; — 


21 1 


— 


8,855 


254 


10 


28 -7 1 13 


! — 


7-9 


— 


8,907 


830 


11 


37 


1-28 1 


1 ~~" 


4-2 


— 


9,616 


183 


11 


19 -8 1 •!« 

1 


J 


10 -34 








29-4 


1-28 



11 -0 
16 
27-3 
42-0 
17-4 



0-83 



23 1 0-20 



2 18-4 0-25 



9.725 


313 


10,683 


224 


10,984 


661 


10,860 


464 


9,919 


750 



11 


32-2 


113 


10 


21-0 


0-94 


11 


51 1 


1-00 


19 


! 41-8 


1-76 


17 


75-6 


1-71 



44 1 1-30 



115 I 38 1-29 



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Google 



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Epidemiological Work in 1906. 159 

great as in the case of the man. Soldiers' wives are attacked in about 
the proportion of two to one as compared with the men. Children 
are the least liable of all to attack. The figures are as follows : — 

Admission Ratios, 1901 to 1905. 

Officers 131-5 per 1000 of strength. 

Soldiers* wives 88*2 „ „ 

N.C.O.'s and men ... 411 „ „ 

Children 23*1 „ „ 

Another very striking fact is the high mortality rate observed 
amongst soldiers' wives. The percentages of deaths to attacks are as 
imder : — 

Percentages of Mortality to Attack, 1901 — 1905. 

Soldiers' wives 5 percent. 

N.C O.'s and men 28 „ 

Officers 1-7 „ 

Children 087 „ 

The special liability of the officer to attack is not readily explainable 
on a general assumption that the occurrence of the disease is usually 
associated with insanitary conditions. At least as much care is 
bestowed on the maintenance of officers' quarters and messes in a satis- 
factory sanitary state as is given to keeping barracks in a sound con- 
dition. He is also as a rule less exposed to possible mosquito bites 
than the man, as many officers use mosquito nets, whereas the men are 
seldom or never protected in that way. Nor can the officer be said to 
be more exposed to the possibility of infection by infected dust. Yet 
the fact remains that he is three times more liable to attack by Mediter- 
ranean Fever than the man. The milk hypothesis seems best to explain 
this greater liability. The officer more often eats foods with milk or 
prepared with milk, at messes, at clubs, or at the houses of his friends. 
Very likely, too, in the past, he often got unsterilised goats' milk with 
tea or coffee, etc., and infection may sometimes have been conveyed in 
cream or milk with fruits or jellies, ices, etc. Bearing in mind the 
extent to which the goats' milk supply of Malta contains the Micro- 
coccus melUensis, if it be granted that the officer is more in the habit 
of consuming milk in various forms, it must equally be acknowledged 
that he is to a corresponding extent more exposed than the soldier to 
chances of partaking infected milk. 

The same reasoning, only in lesser degree, may also afford an 
explanation of the greater liability to attack exhibited by soldiers' 
wives. It may also be pointed out in this connection that Table VII, 
facing p. 158, shows that both women and children had unusually high 
attack rates in 1903 and 1904, which were the years just before the 
dangers attending the consumption of unsterilised goats' milk were 



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160 Major McCuUoch, Major Weir, ami Staflf-Surgeon Clayton. 

known, while in 1905, notwithstanding that there was much 
Mediterranean Fever about, the incidence rate for both women and 
children is much lower than in the two preceding years, a circumstance 
which may be due to attention to instructions which were issued in 
that year enjoining the sterilisation of goats' milk by boiling. 

With regard to the high percentage mortality to attack in the case 
of soldiers' wives, possible explanations may be that the women often 
attempt to carry on their household work too long, and only give in 
when they become very ill, handicapping in this way their chances of 
recovery, and it is also probable that all the cases do not come under 
observation. 

(5) Age and Service in Malta in EekUion to Mediterranean Fever, — The 
following tables show the relation of age and length of service 
to admissions, deaths and invaliding on account of Mediterranean 
Fever during the four years 1902 to 1905. 

Table VIII. — Age in Relation to Mediterranean Fever, 1902 to 1905. 



Age. 


1902-06. 
Aggre. 

gate 
strength. 


Admis- 
sions. 


Deaths. 


Invalids 

sent 

home. 


Ratios per 1000. 


Admis- 
sions. 


Deaths. 


InTalid- 
ing. 


Under 20 yrs. 
20 to 25 „ 
25 „ 30 „ 
30 „ 35 „ 
85 „ 40 „ 
40 years and 
over 


4,827 
14,774 
7,423 
4,206 
3,871 
845 


190 
811 
233 
125 
120 
43 


4 
13 
7 
9 
5 
3 


1 
101 39 -3 
352 ; 54-9 
96 31-3 
49 1 29-7 
38 1 31-0 
16 1 50-9 


0-82 
0-88 
0-94 
2-14 
1-29 
3-55 


20-9 
23-8 
12-9 
11-6 
9-8 
18-7 


85,945 


1522 


41 


652 


42-3 1 114 


18 1 



It will be observed that men from 20 to 25 years of age appear to 
be more liable to attack than men from 25 to 40, and that increased 
liability is again manifested by men over 40 years of age. The 
mortality is, however, markedly less for men under 30 than it is for 
men over that age. Men under 25 show a larger proportion of 
invalids than the older men, but invaliding again shows increase for 
men over 40, a group which has also the highest death rate^ The 
tables for the separate years will be found in the corresponding annual 
A.M.D. Reports, and tables for 1902 and 1903 were given by 
Dr. Johnstone in Part II of the Commission Reports. On making 
a comparison of the statistics for 1902 with those for other years, it is 
observed that the garrison in 1902 contained a larger proportion of 
older men than usual. For instance, comparing 1902, a year of light 
fever prevalence, with 1905, the year presenting the heaviest known 
incidence of Mediterranean Fever, the figures are as follows : — 



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£pidemi(>loi/icaJ Work in 1906. 



161 



Year 


1902. 


1905. 


Age groups. 


Ayerage strength 
(8758). 


Ayerage strength 

(asm). 


Prom 30 to 35 years 

„ 35 .. 40 


1498 609 
1593 \ ^4.*J 


„ 40 years and oyer 


280 


72 



In 1902, also, there would be a more stable garrison, as owing to the 
South African War there would be less movement of men through 
incoming and outgoing troops, and therefore a proportionate lessening 
of susceptible material. It is of interest to note that the war 
years, 1900 to 1902, all showed moderate fever prevalence, taking 
Mediterranean, enteric, and simple continued fevers into account, and 
this was specially the case in regard to 1900 and 1902. The same 
moderate general fever prevalence was observed in 1903, although 
there was in that year a considerable increase in the prevalence of 
Mediterranean Fever. In connection with these years, also, it must be 
pointed out that the Ist, 3rd, and 4th Koyal Garrison Begiments 
formed part of the Malta Garrison from the end of 1901 to 
April, 1904, and that these regiments were largely composed of old 
soldiers. The garrison regiments had a very moderate fever incidence 
throughout their stay in Malta, less than is usually observed in the 
regular infantry regiment Coincident with return to ordinary peace 
conditions, increased fever prevalence made its appearance in 1904, 
reaching a climax in 1905. 



Table IX. — Service in Malta in Relation to Mediterranean Fever, 

1902 to 1905. 



Serrice in 
Malta. 


1902-05. 
Aggre- 
gate 
strength. 


Admis- 
sions. 


Deaths. 


Inyalids 


Ratios per 1000. 


sent 
home. 


Admis- 
sions. 


Deaths. 


Inyalid. 
ing. 


Under 1 yr. 
Ito 2yr». 
2 „ 8 „ 
8 „ 4 „ 
4„ 6 „ 
5 .. 10 „ 
10 yean and 
OTer 


17,820 

11,356 

4,016 

1,197 

712 

657 

187 


839 

454 

140 

41 

14 

32 

2 


14 

12 

8 

2 

1 


815 

231 

58 

19 

7 

22 


47 
39-9 
84-8 
34-2 
19-6 
48-7 
10-7 


0-78 
1 05 
1-99 
8-34 

3-04 
5*84 


17-7 
20-3 
14-4 
15-9 
9-8 
83 -6 


85,946 


1522 


41 


652 


42-8 


114 


18 1 

t 



(2089) 



m 



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162 Major McCulloch, Major Weir, and StaflF-Surgeon Clayton. 

Fifty-five per cent, of the cases of Mediterranean Fever in these 
four years occurred amongst men of under one year's service in Malta, 
and 30 per cent, were men in their second year of service there, so 
that 85 per cent, of the admissions occurred amongst men who had 
been under two years in the garrison, and the invaliding bore almost 
the same proportion. Mortality is, however, much more marked in 
connection with cases occurring after the second year of service in 
Malta. This is shown by the figures in Table IX, but it is even better 
shown in the 1905 table, from which the following figures are taken. 
They represent 16 deaths amongst 643 admissions. 

1906. Death rate per 1000 of strength. 

Under 1 year 1*41 

1 to 2 years 1-66 

2„3 „ 315 

3„4 „ 9-26 

This would appear to indicate either that after the second year men 
are less able to resist the inroads of disease, or that invaliding saves a 
proportion of the cases belonging to the earlier periods. 

In connection with deaths from Mediterranean Fever, it may be 
mentioned that army medical officers in Malta have observed that 
fever cases do badly in a season when " Sirocco " is a marked feature. 
The Cottonera Hospital annual return for 1897 contains the following 
remarks on this point : — *' It was also noted what an influence sirocco 
winds had on the course of fevers. This is a very damp and a very 
depressing south-east wind, and with it came high temperatives 
(patients), great depression and often death." 

(6) ClimcUe in Relation to the Prevalence of Mediterram^an Fever. — In 
Chart 4 the relation of temperature and rainfall to the incidence of 
Mediterranean Fever is shown for the years 1899 to 1906 month by 
month, and in Chart 5, p. 220, general curves for the period 1899 to 1905 
are given. The curves in the latter chart appear to show a definite 
relation between temperature and case incidence, the rise of temperature 
preceding the increase of incidence, while the rise of the rainfall 
curve coincides almost in point of time with the beginning of the 
decline in case prevalence. If, however, the temperature and rainfaU 
curves for the separate years are examined {vide Chart 4) in relation to 
the case incidence of the particular year, it is impossible to make out 
any constant relation of the kind indicated by the combined curves for 
the series of years. It is not even constantly true that the greatest 
incidence corresponds to the hottest season of the year, as, for example, 
it did not in 1902. Again, the climatic conditions of heat and drought 
are associated with a small prevalence of Mediterranean Fever in 1902, 
but with very great prevalence of the disease in 1905. Further, in 



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Epidemiological Work in 1906. 163 

1903, the largest number of oases occurred during the rainy season, 
following a period of prolonged (four months) drought, the chief 
prevalence being in September, October, and November, whereas in 
1905 the chief prevalence was in the dry months, March to the end of 
September. In 1905 Mediterranean Fever reached its highest recorded 
prevalence. The rise began in February, shot up suddenly in May, and 
reached its sununit in September. During this period, i.e., from the 
beginning of February to the end of September, there was only 
4*356 inches of rain out of a total for the year of 25*103 inches. By 
far the greatest rainfall occurred in the three last months of the year, 
October (3*672 inches), November (1*699 inches), and December (9*591 
inches), and coincidently there was a large decrease of fever prevalence. 
It is observed, however, that decrease of a marked character had com- 
menced before the occurrence of any heavy rainfall, and that the 
decline in prevalence continued very markedly during November, a 
month when little rain fell, and before the occurrence of the excessive 
rainfall of December. A possible explanation of such irregularities may 
be found in the presence or absence of an accumulation of susceptibto 
individuals. There must be constant variation in the quantity of 
susceptible material in the garrison, owing to the frequent changes of 
the individuals forming a military population and, as already stated on 
p. 161, we have reason to think that absence of an accumulation o£ 
susceptible individuals marked the year 1902. It should also be^ 
remembered that the numbers of Micrococcus meliiensis excreted in 
the milk of the goat are liable to great variations, which appear to have 
no definite relation to season of the year. 

For the garrison, the period of seasonal prevalence would appear to 
be from May to October (vide Chart 5, p. 220), prevalence being at its 
height in August and September, while the chart also shows that the 
disease is present throughout the year, and that there is nothing much 
to pick and choose between the five months December to April, as far as 
moderate prevalence is concerned, at least that is the case for the period 
1899—1905. 

Section II.— Medfterrankan Fever in the Garrison in 1906. 

During the first four months of 1906 the strength of the garrison 
was, roughly speaking, about 8000 men. The 1st Battalion Lancashire 
Fusiliers left for Egypt on April 30, and they were followed there by 
the 4th Battalion Worcestershire Eegiment on May 8, the strength in 
May being reduced, by the departure of these two regiments and by 
the departure of a detachment of the 2nd Boyal Sussex Regiment for 
Crete, to just under 6000 men. The Worcestershire Regiment returned 
to Malta on June 12, and from that time up to the end of September 
the strength was between 6500 and 6800 men. The Ist Battalion 
(2089) m 2 

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164 Major McCulloch, Major Weir, and Staflf-Surgeon Clayton. 

the Bifle Brigade left for England in October. The Ist Battalion 
Lancashire Fusiliers returned to Malta from Egypt on December 17, 
and the 1st Battalion Royal West Kent Regiment left for England on 
the following day. 

By the departure of the Lancashire Fusiliers in April, Lower 
St. Elmo barracks and the Manoel hutments were cleared, but shortly 
afterwards a detachment of artillery was quartered in Lower St. Elmo, 
to relieve a somewhat congested state of the barracks at Upper St. Elmo 
and St. James Cavalier. Old Floriana barracks were vacated on 
July 11, the men of the 1st Battalion Royal West Kent Regiment, who 
occupied them, being moved to the Manoel hutments, partly because 
Old Floriana barracks have long been regarded as among the most 
unsatisfactory in Malta from a health point of view, and partly because 
there was a persistence of fever cases. All the old barracks in 
Cottonera Lines, which were closed in 1905, have remained closed. 
The small rooms in Tigne Fort still continue to be occupied, although 
they are most ujidesirable as quarters, owing to bad ventilation, 
especially of the lower rooms. Lieut-Colonel Davies stated in last 
year's report that he had been informed that they were to be evacuated 
shortly. St. Francis Barracks, Floriana, were overcrowded at the time 
cases of Mediterranean Fever were occurring in them towards the end 
of May. The beds were very close together. The rooms are very 
high, but the question is one of giving sufficient floor space, and each 
man should have at least 60 square feet superficial area, and no height 
over 12 feet shoidd be used in estimating the cubic space per head of a 
barrack room. The barrack accommodation at Valletta Hospital is 
insufficient for the needs of the detachment of the Royal Army Medical 
Corps, and a small ward had to be taken into use as an additional 
barrack room. With the exceptions mentioned, there was no over- 
crowding and, in fact, the troops were quartered under more satisfactory 
conditions than appears to have been the case in previous years. 

There is no necessity for us to enter upon a detailed discussion of 
.'the sanitary conditions of the various barracks, as they were fully gone 
into last year. We made a preliminary sanitary survey of the barracks 
and camps, in order to make ourselves acquainted with the conditions 
prevailing, and we were constantly in and out of barracks in the course 
of investigation of cases. We are accordingly in a position to state 
that there was much sanitary activity in evidence, both on the part of 
Ae. medical and the regimental authorities, and that the barracks 
generally were maintained in a satisfactory condition. It stands to 
the credit of Malta, that it is one of the first garrisons in which the 
infantry units adopted the plan of having a permanent sanitary staff 
under the orders of the quartermaster of the regiment. This scheme, 
which was commenced in the beginning of June, has worked very 
saturfactorily. and has in no instance hampered in any way regimental 



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Epidemiological Work in 1906. 165 

administration or training, while it has much facilitated the task of 
maintaining barracks in a satisfactory sanitary state. 

The water supply remains as described in previous report««. 
Micrococcus meUiensis has never been found in it xmdev natural conditions. 
We have no evidence which indicates it as a possible vehicle of the 
disease and, indeed, the scattered distribution of the cases of Mediter- 
ranean Fever in barracks, which, as in former years, was also the rule 
in 1906, is against water-borne infection. 

1. Drainage^ Barrack Supplies^ dx. 

Drainage. — There are two important changes for the better to 
report : one in connection with barracks, and the other affecting the 
drainage system of Valletta and the three cities generally. Neither of 
them, however, bears any relation to the prevalence of Mediterranean 
Fever in 1906. The first relates to the conversion of the dry earth 
latrines at Imtarfa Barracks to a water carriage system, the work 
of reconstruction having been commenced in August. The second 
improvement was the flushing of the entire system of town sewers 
twice a day instead of once as heretofore. This change was made late 
in the season in Augiist We have obtained no evidence in the course 
of our enquiries which would connect drainage defects vrith the 
occurrence of any case or cases of the disease. 

Barrack Supplies, — Bread and meat are the only parts of the soldier's 
ration which are supplied by the State. All supplementary food is 
provided imder regimental arrangements. In Malta, the bread is baked 
in a military bakery by men belonging to the Army Service Corps. 
There is a military section at the public abbattoir, from which all the 
meat for the troops comes, the animals having been previously inspected 
by the civil veterinary officer, who is in charge of the abbattoir. The 
groceries are purchased from the regimental grocery bars, which almost 
universally obtain the chief part of their supplies from English sources. 
The regimental institutes, such as coffee bars, etc., are generally catered 
for by Maltese, and the supplies usually come from Maltese sources. 
The grocery bars may be dismissed as selling nothing likely to have 
any direct relation to the causation of Mediterranean Fever. The 
coffee shops in barracks cannot be so lightly dismissed, as milk is used 
in these places. Tea, coffee, cocoa, milk, aerated waters, various kinds 
of cooked foods, bread, cakes, fresh vegetables, fruits, etc., are supplied. 
Condensed milk is the form of milk in general use in the coffee shops, 
but in some instances, up to the time of the milk change being made, 
goats' milk was used. Even after that, we have evidence that it was 
possible to purchase goats' milk at coffee bars in barracks, but this was 
probably not a very common occurrence. However, the fact that it was 
possible to occur at all indicates that these places require careful super- 
vision in this respect. Neither locally made butter nor cheese has ever 



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166 Major McCulloch, Major Weir, and StaflT-Surgeon Clayton. 

been observed in any of the coffee bars in barracks. The bread and 
cakes are usually from Maltese bakehouses, but we have no reason to 
suspect them of conveying disease, and the same is true of the aerated 
waters supplied. Tomatoes, spring onions, lettuce, radishes, cucumbers, 
grapes, apricots, apples, oranges, etc., can all be purchased at these bars 
in their season. Tomatoes and spring onions are in common use in 
some barracks, especially among the artillery and engineers, and are 
often taken uncooked with cheese for supper. These articles are some- 
times eaten unwashed, and in one instance the man told us that the 
tomatoes he had been eating were gritty. The possibilities of these 
vegetables coming from heavily manured ground, or of their lying 
about on contaminated surfaces in Maltese houses and courtyards, 
before they are brought into barracks, which we have ourselves seen, 
must be borne in mind, as they may be potential sources of disease. 
Hawkers very often bring these articles into barracks for sale, and men 
abo purchase them outside barracks. 

Soldier^ Homes. — There are Church of England homes in Valletta 
and at Pembroke, Wesleyan homes in the Floriana and Cottonera 
districts, and a Boman Catholic home in the Floriana district. Tea, 
coffee, cocoa and other refreshments can be obtained, and the homes 
are usually well managed. We were informed that the milk used was 
condensed milk. 

Befreshmeni Bars, Bestaurants, etc, — ^There are many bars and 
restaurants in the neighbourhood of all barracks, where the soldier can 
obtain suppers and other refreshments, both alcoholic and non- 
alcoholic, and among the latter milk has an important place. 

2. Investigaiion of Milk Supplies, including MUk Products. 

It is important to remember that the milk used in barracks is not 
supplied at the expense of the State, and that consequently the milk 
for the different units and officers' messes is obtained under arrange- 
ments which they themselves make. On the other hand, the milk for 
hospitals is a public supply, which is obtained under contract arrange- 
ments made by the officer in charge of supplies. But, whether public 
or private arrangements for the supply of goats' milk were the case, 
the milk was obtained from a large number of different sources. In 
the case of the hospitals, it was not always herds belonging to the 
c<mtractor himself that furnished the milk, but, and this is particularly 
true of the larger hospitals, he gathered together a niunber of small 
owners, and from collections of goats thus made up the required 
quantity of mUk was obtained. There was no guarantee that the 
heirds would be composed of the same goats from day to day. 
Bearing in mind the extent to which the Maltese goat is the carrier of 
the Micrococcus melitensis, it is obvious that frequently changing goats 
must necessarily mean increased risk of the introduction of infected 



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Epidemiological Work in 1906, 167 

milk. In the case of barracks, the herds were more uniform in their 
composition, and here the risk was dependent on the relative number 
of healthy and infected goats in the herd. This, it is thought^ affords 
it probable explanation of the irregular distribution of the disease from 
year to year observed in barracks, and of the want of constancy as 
regards place infection. 

Barracks. — During the first five months of 1906 the garrison could 
be divided into two sections : (1) Units using goats' milk, and 
(2) Units using condensed milk. To the first section belonged the 
1st Battalion Boyal West Kent Regiment, the Jlst Battalion Rifle 
Brigade, the 2nd Battalion Essex Regiment, the 1st Battalion 
Lancashire Fusiliers, the 4th Battalion Rifle Brigadejand the several 
detachments of the Royal Army Medical Corps. To the ^second 
section belonged the Royal Engineers, the Royal Garrison Artillery, 
the 4th Battalion Worcestershire Regiment, and the detachment of the 
2nd Battalion Royal Sussex Regiment. This division refers only to 
the milk used regimentally in bulk for the men's breakfasts^and teas 
in barracks. 

Condensed Milk Units, — It by no means follows that the men of these 
units had no access to goats' milk. On more than one occasion we 
found that goats' milk was brought in for individual use in the case of 
units classed under the condensed milk category. The married 
families, too, of these units were making use of goats' milk in many 
instances. The milk supplies of the several officers' menses was goats' 
milk, or, rarely, cows' milk, which may also convey the micro- 
coccus ; and it is noteworthy that officers' servants and mess waiters 
showed a special liability to contract Mediterranean Fever. The fact 
that condensed milk was the barrack supply did not prevent the men 
from using goats' milk outside barracks, as a study of the histories of 
individual cases will show. It is a popular belief in the artillery, 
amongst other units, that the men did not often contract Mediter- 
ranean Fever in barracks, but that they had to be admitted to hospital 
to get it. 

Cook-houses in Barracks, — Enquiries elicited the fact that it is a 
<;ommon practice for men employed as cooks to taste unboiled milk, 
mostly in order to decide doubts as to quality, but sometimes it was 
taken as a drink. Many of these men had daily opportunities of 
taking unboiled goats' milk, and it is a significant fact that they 
jshowed special liability to attack by Mediterranean Fever. Some 
instances have already been given, and others will be found in the 
•details relating to the investigation of cases. 

Use of Milk outside Barracks. — A census of the men of the West 
Kent Regiment was made in April as to their milk-taking habits 
outside barracks. The evidence obtained was that, out of 696 men 
questioned, 153 stated that they had drank goat<}' milk outside 



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168 Major McCulloch, Major Weir, and Staft-Surgeon Clayton. 

barracks, some frequently, others occasionally. The forms in which it 
was taken included goats' milk plain, soda and milk, egg flips, rum and 
milk, ice cream, milk puddings, and occasionally milk with porridge. 
Besides the men referred to here, many other men in the regiment 
had taken tea and coffee outside, to which goats' milk had been added. 

During the investigation of cases in barracks, many other parties of 
men were questioned, and similar information was obtained ; for 
instance, out of a party of 36 artillerymen, 17 stated that thej 
occasionally drank goats' milk outside barracks. 

It is also fairly common for soldiers to purchase goals' milk from 
itinerant vendors at Pembroke Camp. It must be borne in mind, in 
connection with the division into goats' milk and condensed milk 
imits, that both classes of units come to this camp for their musketry 
course. 

Ice creams, and soda and milk are very freely taken by soldiers and 
by soldiers' wives and children during the hot weather months. 

We satisfied ourselves by personal investigation that goats' milk was 
to be obtained in the restaurants, and in many of the bars frequented 
by soldiers. Some bars have quite a reputation for egg flips. We 
have also seen goats tethered in bars. There must be a demand, or a 
source of supply would not be on hand. 

Hospitals. — The supply in all the military hospitals was goats' milk 
up to the latter part of May, 1906. 

It was ascei;tained that the cooks in hospital kitchens were in the 
habit of tasting unsterilised goats' milk, when there was any doubt as 
to its quality, a practice already pointed out as also common in cook- 
houses in barracks, and here again cooks show special liability to 
attack. 

In some instances, Mediterranean Fever has been contracted by men 
whose duty it was to superintend the milking of the goats. 

Many soldiers appeared to contract the disease in hospital, and in 
such cases there was generally evidence that the man had been on milk 
diet, or that he had been getting milk as an extra. 

Soldiers^ Families, — A house-to-house visitation of soldiers' families 
yras made, and it was found that some families used condensed milk 
alone, some both condensed milk and goats' milk, while others used 
goats' milk entirely. The details of this investigation are given 
on p. 211. 

(1) Milk Pre^atUiom, pior to the Milk Change ; Barracks and Married 
Q^iarters, — The infectivity of goats' milk was recognised in 1905, in 
which year orders were issued by commanding officers that all goats' 
milk for the use of the men in barracks was to be boiled, and the 
married people were enjoined to make use of the same precautionary 
measure. In order to prevent soil pollution, goats were ordered to be 
excluded from barracks, and milking places were {^^inted which 



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Epidemiological Work in 1906. 169 

were usually just outside the precincts of the barracks or hospital. 
These instructions remained in force as long as goats' milk continued 
to be used. 

HospiUds, — The goats' milk used in Valletta and Cottonera Hospitals 
was pasteurised in Aymard sterilisers, a proceeding which dates back 
to 1904, while in the hospitals at Forrest, Citta Vecchia, Imtarfa and 
Gozo sterilisation by boiling was practised. Taking Valletta Hospital 
as the example, the details as to milk precautions were as follows : 
The average daily quantity of milk used in this hospital, speaking 
roughly, varied between 180 and 200 pints in the cold weather 
months, and between 750 and 800 pints in the hot weather months. 
A non-commissioned officer and three men were told oflF to superintend 
the milking of the goats, and each milking was done in the presence 
of the non-commissioned officer and one of the men. The milk was 
supplied three times a day, at 6.45 a.m., at 9 A.M., and between 2 and 
3 P.M. ; and in the hot weather months a fourth supply was usually 
obtained at 6 P.M. The milk was placed in the Aymard steriliser, and 
it was raised to a temperature of 196'* F. If the water in the outer 
chamber of the steriliser was boiling when the milk was put in, the 
temperature of 195** F. was reached in 20 to 25 minutes, and the milk 
was then kept at this temperature for five minutes. The whole 
process, therefore, takes over half an hour, and the milk has to cool 
afterwards. The milk cans were all scalded in the hospital kitchen. 
Special covered cans were used for conveying the sterilised milk from 
the kitchen to the wards. 

(2) Failure of Sterilisation, — The precautions to ensure that only 
sterile goats' milk was supplied to the troops were excellent, as far as 
the issue of orders could make them, and theoretically they should 
have done away with all risk of the spread of the disease through the 
use of infected milk. But it must be remembered that such sterilisa- 
tion has to be entrusted to human agency, and it was therefore likely 
to fail altogether at times, and if circumstances arose which might 
seem to require that the process of sterilisation should be hurried, it 
was liable on those occasions to be incompletely carried out. That it 
did fail is certain, as Colonel MacNeece, the Principal Medical Officer 
of the Malta Command, informed us that, in the beginning of 
September, 1905, he had to call the attention of officers commanding 
to the fact that in some corps goats' milk had not been boiled before 
use, and he asked that stringent orders might be issued that this must 
be done by troops and married families. Later, we again find that, 
while he considered the sterilisation of the hospital milk as generally 
satisfactory, he still regarded it as doubtful in the case of the troops, 
and still more doubtful in the case of the soldiers' families, notwith- 
standing the orders on the subject. Soon after we began our 
investigations, doubts as to the completeness of the milk sterilisation 



Digitized by VjOOQ IC 



170 Major McCulloch, Major Weir, and Staflf-Surgeon Clayton, 

became so strong in our minds that we cast about for some means of 
distinguishing boiled from imboiled milk, and in consultation with the 
laboratory members of the 1906 working party it was decided to 
make use of the *' Ortol " test. 

There are several reagents which give colour reactions with unboiled 
milk, such as hydroquinone, guaiacol, pyrocatechine, and ortoL The 
*^ ortol " test was suggested by Said in tiie ' British Medical Journal,' 
March 21, 1903, for distinguishing between boiled and unboiled milk. 
It does not distinguish raw from pasteurised milk, as no reaction is 
obtained until a temperature of 75 *" C. is reached. Two solutions are 
required: (1) a solution of ortol, and (2) a solution of peroxide of 
hydrogen. A few drops of each, added in the order named, give an 
instantaneous rich rose colour with unboiled milk, no change of colour 
being observed if the milk has been boiled. The use of the test was 
started on May 16, and during the next three weeks neglect of 
boiling goats' milk was detected on six separate occasions. Three of 
these were in connection with an officers' mess in which cases of the 
disease had been persistently appearing. The supply of this mess was 
changed to condensed milk, after which no further cases occurred. 

(3) Labaraiary Examinations of Milk, — Samples of goats' milk from 
barracks and hospitals, of tea with added milk from barracks, and of 
milk and butter from an officers' mess, were examined for the presence 
of the Mia-ococcus nielitensis, but on each occasion with a negative 
result. 

(4) Grouped Cases with a Common MUk Supply, — The cases that 
occurred in the West Kent Regiment, both in barracks and in the 
officers' mess — six of the cases observed in the Misida Bastion married 
quarters, five cases occurring in three families, living in GU)vemment 
quarters in Floriana, a long distance away from any of the cases just 
mentioned, and the case of an officer living in rooms in another part 
of Floriana — all had their milk from the same goat-herd. No other 
relation in common could be discovered, and we know that the herd 
contained infected goats. 

(5) Examinations of Goats, — The work of the Commission in 1905 
established the facts that a large proportion of the goats examined 
gave a positive reaction, and that the milk of such goats often con- 
tained the disease germ. Amongst the goats examined in 1905 were 
the following herds supplying milk to the troops : — 

1. Valletta Hospital A small herd of 13 goats was examined; 
four gave a positive reaction, and the milk of one yielded the specific 
micrococcus. 

2. Citta Yecchia Sanatorium. There were 15 animals in tiie herd ; 
1 1 were found to react, and five gave infected milk. 

3. Forrest Hospital. Fifteen goats were examined; five reacted, 
and from the milk of one the micrococcus was recovered. 



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Epidemiological Work m 1906. 171 

The following herds were examined in 1906 : — 

1. Herd supplying the Ist Battalion Boyal West Kent Regiment. 
Owing to the prevalence of Mediterranean Fever amongst the officers 
and men of this regiment, and amongst the married people living in 
the Floriana district, the goats of the herd supplying Floriana 
Barracks with milk were examined in the first week in May* The 
«ame herd also supplied the officers' mess and a number of soldiers' 
families. This herd consisted of 40 goats, 10 of which gave a 
positive reaction, and from the milk of three the Micrococcus melUensis 
was separated. 

2. Herd supplying the 1st Battalion Rifle Brigade* This battalion 
continued to have goats' milk after all the rest of the garrison had 
changed to condensed milk. Owing to the occurrence of cases of 
Mediterranean Fever in July, the goats of the herd supplying the 
mUk were examined on the 25th of that month. The herd consisted 
of 81 milch goats, pregnant goats, kids, and billies. Forty-six of 
the goats were in milk, and six of them gave a positive reaction, and 
the micrococcus was recovered from one. Thirty-one specimens of 
blood from the other goats were examined, and 20 of them were found 
to react 

3. Valletta Hospital. This herd, or rather the collection of small 
herds which went to make it up, numbered over 60 goats. It was 
intended to have examined the whole herd, but owing to objection 
on the part of the goat-herds, samples of milk from 18 goats only 
were obtained. Of these six reacted, and the Micrococcus meliiensis 
was isolated from one. 

4. Citta Yecchia Sanatorium. Thirty-eight examined; 12 gave a 
positive reaction, and the milk of three yielded the germ. 

5. Forrest Hospital. Eight goats were examined; all were found 
to be healthy. 

6. Imtarfa. Sixty goats were examined, and two gave a positive 
reaction, but the milk of neither yielded the Micrococcus meliiensis. 

It must, of course, be remembered that some of the goats, giving 
reactions only, would at other times probably be excreting Micrococcus 
vidiiensis in their milk. From an epidemiological point of view, 
therefore, reacting goats must be considered as potential sources of 
danger. 

There is evidence that the proximity to living quarters of places 
where goats are penned, or milked, or which are used as resting places 
for the goats, is attended by danger of the disease being conveyed to 
those living in such quarters, and we think that the fly is often a 
carrier of infection in such circumstances, and that the disease is more 
likely to be spread by it than through the medium of infected dust. 
This appears to be the most likely explanation of the occurrence of the 
disease in Cases 29 and 30 of the West Kent series {vide p. 187). 



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172 Major McCuUoch, Major Weir, and Stafif-Surgeon Clayton. 

It is possibly also the best explanation of the cases which occurred 
in 1904 and 1905 among the nursing sisters at Cottonera. Da vies 
informs us on p. 151, Part FV, of the Commission Reports, that it had 
been the practice, until July, 1905, to milk the goats that provided 
milk for the patients on a plot of ground within a few yards of the 
nursing sisters' quarters, and that there is no doubt that this area, 
was extensively fouled every day for a long period. No cases have 
occurred amongst the nursing sisters at Cottonera Hospital since the 
goats were removed from this spot. 

(6) Discontinuance of the use of Goak^ Milk in Haspitah and Barracks. — 
Even if there had been no other facts to go on than that a large 
proportion of the goats in Malta were infected, and that their milk 
was a common vehicle for the Micrococcus 7nelitensi% we consider that 
we would have been justified in recommending the discontinuance of 
the use of goats' mUk. But, as early as the beginning of May, the 
evidence collected had lent strong support to the view that infected 
goats' milk was a factor of the highest importance in connection 
with the spread of Mediterranean Fever. The use of milk was a 
factor which assumed special prominence in the investigation of cases 
of the disease. It seemed best to explain the occurrence of cases 
amongst cooks, officers' servants, hospital patients, etc. It was the 
one common factor that appeared to be associated with the wide- 
spread distribution of the disease, and it was the one common vehicle 
which is known to convey the specific micrococcus. Moreover, we 
had completed the milk census of the West Kent Regiment, and, as 
the result of special prevalence of the disease in that regiment, 
the herd supplying the milk had been examined and had been found 
to be infected. There was, therefore, the association of an infected 
herd of goats with the special prevalence of the disease in a particular 
body of men. Doubts had arisen as to the efficiency of milk 
sterilisation, more especially in barracks, but milk infection was a 
certainty. The obvious course, therefore, was to cut off the supply 
of the infected article, both from barracks and hospitals. In 
discussing the matter with officers and others in barracks, we had 
frequently been met with the remark, " But, if goats' milk is dangerous, 
why is its use continued in hospitals " 1 We found that the regimental 
authorities were unwilling to move in the direction of change until 
a lead had been given by the hospitals. The situation was discussed 
with the Principal Medical Officer, Malta, who referred the matter 
to the Commander-in-Chief, and, on May 12, orders were issued for 
the discontinuance of the use of goats' milk in the military hospitals, 
as a tentative measure, and for its replacement by condensed milk. 
This change came into operation in the various hospitals between 
May 18 and 22, and at the same time the use of goats' milk by the 
various detachments of the Royal Army Medical Corps also ceased. 



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Epideviiological Work in 1906. 173 

As the milk supply to barracks and to officers' messes is not a 
public supply, but is one arranged for by the units themselves, it 
was decided to try first to get commanding officers to make the 
change from goats' milk to condensed milk themselves, and also that 
they should be communicated with direct in the matter, rather than 
through the medium of orders. Accordingly, direct representations 
were made to the various commanding officers, but before any practical 
steps were taken the accomplishment of the desired change was 
greatly facilitated by the occurrence of a strike of the goat-herds. 
The strike began on May 15 and ended on June 1. It was distinctly 
useful in getting the use of goats' milk discontinued in both barracks 
and officers' messes, as the goat-herds themselves stopped supplies, 
-and they had only themselves to blame when they found that their 
customers, having made other arrangements, refused to go back to 
them. The supply of goats' milk was not cut off completely during 
the strike, as one regiment, at least, got its usual supply throughout 
the period. There was still some hankering after goats' milk on the 
part of some units, but at the request of the Principal Medical Officer 
a lecture was given on the subject of Mediterranean Fever to the 
officers and warrant and non-commissioned officers of the garrison. 
This was followed by the almost universal adoption of the milk 
change, and also by another useful step, namely, the establishment 
of permanent sanitary staffs in connection with several of the infantry 
units. By the end of the first week in June all the units of the 
garrison were using condensed milk, with the single exception of 
the 1st Battalion Rifle Brigade, which continued to use goats' milk 
up to the time the battalion left Malta for England in October. 
This regiment was not pressed to make the change, as it was known 
to have very complete arrangements for the sterilisation of the milk, 
and from the personal equation point of view it was felt that the 
individuals concerned in the supervision of the sterilisation could 
be trusted. There was also the further reason that it to some 
extent provided a control, which might in the end prove useful for 
purposes of comparison in connection with the milk change. In 
this connection it is a significant fact that cases of Mediterranean 
Fever were admitted from the 1st Bifle Brigade in July, August, 
and October, whereas the 4th Rifle Brigade, which occupied the 
neighbouring barracks of St. George's, Pembroke, and which had 
adopted the condensed milk change, had its last admission for the 
disease in May. 



Digitized by VjOOQ IC 



174 Major McCulloch, Major Weir, and Staff-Surgeon Clayton. 



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Epidemiological Work in 1906. 



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Digitized by VjOOQ IC 



176 Major McCulloch, Major Weir, and Staff-Siirgeon Clayton. 

In five of the cases debited to January, and in one debited to 
February, the diagnosis was then made, but the men were admitted 
to hospital in the previous year. These cases have been included 
in the 1906 figures, as they did not appear in the 1905 returns. 

1. Prirate P., F Gompanj, Rojal West Keni Begiment. — Admitted October 5, 
1905, from Room 3, Old Floriana Barracks. He had been employed in the cook- 
house for two months before admission. He was on milk in hospital from 
December 4 to December 12, 1905. A positire serum reaction was first obserred 
on January 26, when Mediterranean Fever was diagnosed. 

2. Priyate L., Q Company, Boyal West Kent Begiment. ~ Admitted for simple 
continued fever on November 13, 1905, to Cottonera Hospital, and transferred to 
the sanatorium at Citta Veccliia on December 24, where Mediterranean Ferer 
supervened 21 days aft«r transfer. He was on milk in Cottonera Hospital from 
November 22 to November 30, 1905, and again, at Citta Yecchia from January 2, 
1906. 

3. Gunner S., No. 1 Company, Boyal Garrison Artillery. — Admitted for 
bronchitis on December 31, 1905, and disease was changed to Mediterranean Fever 
on January 18, 1906. 

4. Private £., 1st Battalion Bifle Brigade. — Admitted for rheumatism on 
December 31, 1905, from F Block, St. Andrew's Barracks. The disease was 
ohanged to Mediterranean Fever on January 21, 1906. There is a history that 
this man drank goats' milk freely prior to admission. 

5. Gunner S., No. 65 Company, Boyal Garrison Artillery. — Admitted for 
gonorrhcpa on December 31, 1905, from Boom 40, Upper St. Elmo Barracks. The 
disease was changed to Mediterranean Fever on January 10, 1906. 

6. Bombardier S., No. 102 Company, Boyal Gurrison Artillery. — Admitted for 
psoriasis to Valletta Hospital on October 17, 1905, and transferred on December 6 
to the sanatorium at Citta Yecchia, where symptoms of Mediterranean FeTer 
were observed on February 6, 1906, and a positive serum reaction was obtained 
four days later. 

Distribution of Cases, 

Of the 163 admissions for Mediterranean Fever in 1906, 19 were 
re-admissions for the disease. The re-admissions were distributed in 
units as follows : — 1st Royal West Rent Eegiment, six ; Royal Garrison 
Artillery, five ; 1st Lancashire Fusiliers, four ; 2nd Essex Regiment, 
three; and Army Ordnance Corps one — and in point of time: 
January, four ; February, three ; March, one ; May, one ; June, two ; 
July, two ; September, three ; and October three. 

Excluding re-admissions, the cases which occurred in the four 
quarters of the year were as follows : — 

January to March. April to June. July to September. October to December. 
44 68 25 7 

Two points should be borne in mind in regard to these figures — 
{1) that the second six months is the half of the year when 
Mediterranean Fever is usually most prevalent, and (2) that the first 
^ix months was tUe period before the milk change, while during the 



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Epidemiological Work in 1906. 177 

second six months goats' milk had been discontinued in all the 
hospitals, and in all but one of the barracks. 



4. Prevalence in Units. 

Royal Garrison Artillery, — As has already been indicated, and as 
will be seen later when the individual cases are being discussed, 
a considerable number of the cases which have occurred in the artillery 
units were those of men who have taken goats' milk either in or 
outside barracks, while some of the others are instances in which there 
is a strong probability of the disease having been contracted in 
hospital. The artillery units show a very marked decrease of 
prevalence during the second half of the year, with 16 admissions 
against 35 in the first six months. 

\st Battalion Rifle Bngade. — This battalion arrived in Malta on 
April 20, 1904, from England. They were quartered in Manoel 
Barracks for the first 13| months, and were moved in June, 1905, to 
the newly built St. Andrew's Barracks, of which they were the first 
occupants. Mediterranean Fever appeared in the regiment six weeks 
after its arrival, and cases occurred every month afterwards up to 
January, 1906. There was then freedom from fever cases until May. 
On the occurrence of three cases in July, the goats supplying the 
battalion with milk were examined, and the herd was found to be 
infected. It is of course possible that the disease was contracted 
outside barracks, but we failed to trace any outside source, and as we 
know that the milk was coming from an infected herd of goats, 
notwithstanding the very strict supervision exercised over the boiling 
of the milk in this battalion, failure of sterilisation cannot be excluded. 

Uh Battalion Rifle Brigade. — This battalion arrived from England 
on November 16, 1905, and were quartered in St. George's Barracks, 
Pembroke, which are in the near neighbourhood of the barracks of the 
Ist battalion of the regiment. The first case of the disease occurred 
four and a half months after arrival, and there have been five cases in 
all, one in April and four in May. There have been no cases since 
the milk supply of the battalion was changed to condensed milk. 

2nd Essex Regiment, — Arrived in Malta from England on April 28, 
1904, This regiment suffered severely in both 1904 and 1905, when 
it contributed 79 and 113 admissions respectively. During the first 
14 months of its stay it was stationed at Lower St. Elmo, after which 
it was moved to Imtarfa, where it has since remained. There have 
been only nine admissions in 1906, six in the first half of the year 
and three in the second. Of the latter, one was a case from Gozo, and 
both in this and one other of the three cases there is a history of 
taking goats' milk. The milk supply of the regiment was changed 
from goats' milk to condensed milk on June 7. 

(2089) n 

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178 Major McCulloch, Major Weir, and Staflf-Surgeon Clayton. 

Isi BaUalion Lancashire Fusiliers. — This regiment came from 
Gibraltar to Malta on February 27, 1905, and the first eases of 
Mediterranean Fever were admitted in the following April, and cases 
occurred every month until the regiment left for Egypt on April 30, 
1906. There were 75 admissions in 1905, while in 1906 there were 
eight admissions, four of which were re-admissions, two in the first three 
months of the year and one each in September and October. Two 
cases of Mediterranean Fever were admitted in Egypt on July 7, one 
from the officers' mess and the other from No. 5 £oom, L Block, 
Citadel Barracks. Both men arrived from Malta on May 3. Cows 
are kept at tfie Citadel Barracks, and this milk is not boiled before 
issue. We have no information as to the presence or absence of the 
Micrococcus meliiensis in milk in Egypt The regiment returned to 
Malta from Egypt on December 17. 

2nd Battalion Royal Sussex Regimeni. — The headquarters and 500 men 
of this regiment left Malta for Crete on May 29, 1905. A detachment 
remained and were quartered in Imtarfa Barracks until April 30, 1906, 
when it left Malta to join headquarters. There were no cases of 
Mediterranean Fever in 1906 up to the time of its departure. The 
milk supply was condensed milk. 

4tk BaUalion Worcestershire Regiment. — This regiment arrived in 
Malta from Barbados on December 2, 1905, and were quartered in 
Verdala Barracks. The first case of Mediterranean Fever was 
admitted on February 11, 1906, but we have no evidence as to the 
probable source of the disease, except that the man was in hospital 
from December 2 to 12, 1905. The second case was admitted 
on April 16, and was that of a married man, whose child was 
admitted for Mediterranean Fever on March 2, and for both cases 
there is a goats^ milk history. The milk supply of the regiment is 
condensed mOk, dating from its arrival in Malta. The regiment was 
sent to Alexandria, where it arrived on May 11, and it returned to 
Malta on June 12. Six cases of Mediterranean Fever were admitted 
during its month's stay in Egypt. There was an entire absence of 
Mediterranean Fever from the garrison of Alexandria until the 
arrival of the Worcestershire Regiment from Malta, and the only 
cases then observed were those among the men of that particular 
regiment. We have been unable to obtain any evidence which throws 
any light as to the source of the disease in these six cases. The men 
appear to have been admitted for simple continued fever in four of the 
cases and for rheumatism in the other two, and the disease was 
changed afterwards to Mediterranean Fever. A positive serum 
reaction was obtained in each of the six cases. After returning to 
Malta, two more cases were admitted in August ; one was a man who 
had been feeling out of sorts ever since his return from Eg3rpt, the 
other was a man admitted on August 13 from Gk>zo, where he had 



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Epidemiological Work in 1906. 179 

been stationed since July 2, and where he had been employed as 
a cook. There is no evidence of the use of goats' milk in either of 
these cases. Another case was admitted in December, but of this case 
we have no particulars. 

The units showing the greatest prevalence of Mediterranean Fever 
in 1906 were the 1st Battalion Royal West Kent Regiment and the 
Royal Army Medical Corps, the special prevalence, however, being 
confined in both instances to the first half of the year. The details 
are given fully in the following section of the report dealing with the 
analysis of cases of Mediterranean Fever. 

5. Analysis of Coi^ea of Mediterranean Fever, 

Though the analysis of the cases generally only gives brief details, 
yet each case was examined in a systematic manner on a special form 
arranged for the purpose. We found the forms of very great 
assistance in recording cases. The principal points noted in each case 
were : 1. The barrack room or place from which each case was 
admitted. 2. Th^ date of the onset of attack, together with 
a history of the man's previous state of health, and the date on 
which his blood reacted against Micrococcus meliiensis. 3. Date of 
admission. 4. Whether a first attack or relapse. 5. Movements 
since arrival in Malta, giving dates which were confirmed by reference 
to official information obtained from the unit to which the man 
belonged. 6. More particular information about the man's move- 
ments during the 30 days before he got ill. 7. Particulars of 
previous illness in Malta from his medical history sheet. 8. If single 
or married, in the latter case enquire re health of other members of 
family. 9. Conduct and habits, teetotaller, moderate drinker, drinks 
freely, and enquiries as to visits to brothels, giving dates. 
1 0. Actual nature of employment : on this point we found it to be of 
the very greatest importance to get full information, as it gradually 
came out that certain employments were found to be frequently 
associated with attacks of Mediterranean Fever ; for example, cooks, 
mess waiters, and oflicers' servants. 11. Any special hard work or 
exposure during 30 days before illness. 12. Any facts bearing on 
defective drainage, dust, latrines, urinals, etc. Whether employed in 
cleansing w.c.'s,, urinals, or moving urine tubs during 30 days 
preceding illness. 13. Facts concerning milk consumed, including 
butter, cheese, or other articles into the composition of which milk 
enters. If the man had consumed any fresh goats' or cows' milk 
during the 30 days preceding ; give dates if possible. 14. Apart from 
barrack ration meals, particulars relating to articles partaken of in 
barracks, such as milk, other foods, imcooked vegetables, fruits, aerated 
waters, etc. 15. Articles of like nature partaken of outside barracks 
(2089) n 2 

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180 Major McCulIoch, Major Weir, and Staflf-Surgeon Clayton. 

and where ; dates if possible. 16. Facts relating to mosquitoes and 
other biting insects (a) in barracks ; {b) out of barracks. 17, What 
contact has there been with recent cases of the disease (a) personal f 

(1) Contact with previous cases before their removal to hospital. 

(2) Presence of convalescents in barrack rooms; this included blood 
examination and, in some cases, examination of urine, {b) Through 
clothing and bedding, (c) Issue of articles from store. 18. Position 
of bed in barrack room and relation, if any, to previous casee.^ 

19. Precautionary measures adopted with regard to previous cases. 

20. Miscellaneous facts in relation to each case. 

During the year 1906, up to the end of September, 153* cases of 
Mediterranean Fever had occurred among the non-commissioned officers 
and men of the British troops in Malta. Of these, 108 are possible 
cases of infection through goats' milk, Le.y 70 6 per cent, of the cases. 
They are cases (1) of men who are known to have drimk goats' milk 
freely, the soiu*ce of which was known later to have been from a herd 
which contained infected goats. (2) Of men who are known to have 
drunk freely goats' milk about the source of which nothing is known, 
beyond the fact that they got it from a passing goat-herd, or in a 
restaurant, or in the houses of private individuals. (3) Of men who 
had taken goats' milk in egg flips or with rum in different public- 
houses. (4) Of cooks who said they only drank it boiled. (5) Of men 
who drank goats' milk in hospital. (6) Of men who said they only 
had it in tea other than the regimental tea. (7) Of men who said they 
only had it in tea in barracks. 

The last group is a small one, but, we believe, not an unimportant 
one, though we have not classed any of these cases among those of 
probable milk infections. The incidence of the disease on goats'' 
milk-drinking regiments is an argument in favour of the inclusion 
of such men as possible cases of infection through milk. The^ 
1st Rifle Brigade in St. Andrew's Barracks, the newest and best- 
run barracks in Malta, gave nine cases of Mediterranean Fever 
during the year. This regiment continued to use goats' milk for the 
men's tea until they left Malta on October 1, 1906. The 4th Rifle 
Brigade, which lay near the 1st Rifle Brigade in St Ceorge's 
Barracks, gave five cases of Malta Fever. This regiment discontinued 
the use of goats' milk on May 15, and their last case of Malta Fever 
was admitted to hospital on May 29, 1906 (Private M.). The last ca8& 
from the 1st Rifle Brigade was admitted to hospital on October 19- 
(Private P.). 

The Royal West Kent Regiment had 44 cases. This regiment 
discontinued the use of goats' milk on Ma^ 15. Up to June 15» 
35 cases took place, or 79*5 per cent, of all the cases, while only nin& 

^ The total number of cases for the year is 168, the 10 further admis8io&» 
occurred after we had left Malta. 



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Epidemiological Work in 1906. 181 

•eases, or 20*5 per cent., took place between June 15 and the end 
of September, the time of greatest prevalence in past years. These 
^figures really understate the case, as two out of the nine cases include 
two relapses, one, Private H. H., a relapse from June 15, 1906, and 
•Corporal T., a relapse from November 27, 1905, and another man, 
Lance-Corporal R., who was admitted on July 9, 1906, used to get 
goats' milk to the middle of Jime, and must therefore be included 
in the list of possible milk infections. The figures thus corrected give 
86*4 per cent, of possible milk infections. 

The Royal Army Medical Corps gave 18 cases up to the end of the 
year. The use of goats* milk was discontinued at Valletta Hospital on 
May 21, at Cottonera Hospital on May 22, 1906, at Forrest Hospital 
•on May 18, 1906. Fifteen of the 18 cases occurred before or a few 
•days later than June 22, while of the remaining three cases, one. 
Private J., admitted on June 19, 1906, but ill since June 11, 1906, 
acknowledged that he had drunk unboiled goats' milk about a fort- 
night before the condensed milk was taken into use, i.^., on or about 
May 8, and another of the cases was that of Lance-Corporal J., 
who was almost certainly infected while working in the laboratory 
•of the Mediterranean Fever Commission, and the last was the case of 
Private B., admitted September 16, 1906, but who had been feeling 
unwell practically since May. (See Case 18, Royal Army Medical 
-Corps.) It is thus seen that 88*9 per cent, of the Royal Aimy 
Medical Corps cases occurred before goats' milk was stopped in the 
hospitals. The Royal Army Medical Corps furnished 11*4 per cent. 
of all the cases during the year. 

Though we do not think that all these cases were milk infections, it 
is a striking fact that so many cases occurred during the time goats' 
jnilk was in use in the hospitals, and so few after its discontinuance. 

The cases have been divided into the following groups : — 

Series 1. — The cases in the 1st Royal West Kent Regiment. 
Series 2. — The cases in the Royal Army Medical Corps. 
.Series 3. — Hospital cases. 

Examination of the Diet Sheets of patients in Valletta 
Hospital during 1906. 

tSeries 4. — Other cases of possible milk infection. 
.Series 5. — Cases in which the patients were probably infected through 
animals other than goats. 

Series 1. — The Cases in the \st Battalion Royal West Kent Regiment. 

This regiment, as in the previous year, occupied Old Floriana Barracks, 
"New Floriana Extension, and Notre Dame Ravelin Barracks and Huts, 
.and Salvatore Counter Guard, The structural arrangements and 
^sanitary shortcomings of the old barracks have been fully detailed by 



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182 Major McCulloch, Major Weir, and Staflf-Surgeon Clayton. 

Lieut.-Colonel A. M. Davies in last year's Eeport, and need no 
recapitulation here. Suffice it to say that the local authorities had 
done their best to remedy such defects as were remediable, and had 
taken good care, by provision of ample tentage, that no overcrowding 
took place in the casemate rooms. Further, on the recommendation of 
CJolonel MacNeece, Principal Medical Officer, Malta Command, the case- 
mate barracks were evacuated on July 11, 1906, and the portion of the 
regiment thus displaced was quartered in Fort Manoel Hutments. 
This regiment, in 1906, up to their departure from Malta in October, 
gave 44 cases, or, excluding six relapses, 38 cases. Of these, 40 
occurred up to the end of July, and only four during August and 
September. It mu^t be understood that the change to Manoel 
Hutments affected only about 250 men of the regiment, the rest of the 
regiment remaining in New Floriana Extension and Notre Dame 
Ravelin and Salvatore. The position of the Civil Hospital over the 
regimental offices and facing the casemate barracks has been remarked 
upon by Lieut.-Colonel Davies. We noticed the presence of numerous 
flies in Old Floriana •Barracks, in spite of the fact that the barracks 
were kept in a very clean condition. This regiment, on the suggestion 
of the Commission, adopted the plan of ha\ing a fixed establishment 
told off permanently for sanitary work, and it was very well done. We 
had noted the presence of very many flies in the Civil Hospital, and 
we have little doubt that the Civil Hospital was the principal source of 
the flies in Old Floriana Barracks. The Civil Hospital contained many 
cases of Mediterranean Fever, and we think that the common fly may 
be regarded as a possible carrier of germs from milk and possibly from 
infected urine. Another noticeable feature of the surroundings of 
Floriana Barracks, old and new, was the large number of goats which 
were constantly crossing the regimental parade ground on the way to 
and from Valletta and Misida, and Valletta and Hamrun. Further, it 
was the custom to keep a herd of goats at the back of C Block, Floriana 
Extension, in a small ravine shaded by trees, all day and every day. 
There were always swarms of flies in this ravine, on and about the 
goats, and' the place was used as a latrine by the goat-herds. This 
ravine was at a veryj short distance from the back of the barracks. 
Another herd of goats was kept in the ditch between Floriana Extension 
Barracks and the back of the new married quarters, Misida Bastion. 
This herd used to graze on the slope of the ditch at the back of the 
married quarters. We inspected many sheds in which goats were kept 
in Malta, and always noticed nimibers of flies upon the goats. This 
was so marked as to force them on our attention as possible or rather 
probable carriers of infection. 

We will now discuss Jn detail the cases of the West Kent Regiment 
during 1906 :— 



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Epidemiological Work in 1906. 183 

1. Priyate P., F Company, was admitted to Valletta Hospital on October 5, 
1906, and his blood was found to react on Jnnuarj 26, 1906. He had been in 
No. 8 Boom, Old Floriana Barracks, for six months, and he was the first case 
which had occurred in his company for orer six months. He had been in hospital 
in May, 1905, with sore throat. There is no evidence of contact. This man 
drank unboiled goats' milk and soda water, egg flip, and took porridge and milk 
fUtside barracks, in fact, was a fairly free milk drinker up to the time he got ill. 
His history makes it clear that he exposed himself freely to the risk of infection 
through milk. 

2. Prirate L., G (Jompany (see Hospital List No. 1). We think the disease 
was contracted in Citta Vecchia Hospital ; if the disease was Mediterranean Fever 
from the beginning of his illness, it was possibly contracted through fly infection 
from the herd at the back of C Block, New Floriana. This man was not personally 
interviewed by us, as he was invalided before we reached Malta. "We therefore 
know nothing about his drinking milk or not before he went to hospital; we 
do know, however, that he had been employed in a cook-house for two months 
before he got sick. 

3. Priyate D., C Company, was admitted from No. 14 Boom, Notre Dame 
Rarelin, on January 10, 1906, and was a relapse from December 27, 1906. He 
had been in Valletta Hospital — October 28 to November 13, 1906 — with enteric 
fever, and again — November 27 to December 27, 1903 — with Mediterranean Fever. 
He had been in Boom 14 before both of these admissions, and had been company 
cook for three months before his enteric admission. This man states he never 
drank milk except in his tea. His occupation of cook makes the statement 
suspicious. No other case occurred in the room, and no other case had occurred 
for the previous six months. The disease may have been contracted in Valletta 
Hospital, where he had enteric, or in his work as a cook, when he had to handle 
milk and milk vessels. 

4. Private O., C Company, was admitted from No. 6 Boom, Notre Dame, on 
January 23, 1906. He had been in this room since he came out of hospital on 
November 27, 1906. He then was in from November 7 to November 27 with 
simple continued fever, and had exactly the same symptoms as he had in the 
present attack. On that occasion his blood did not react. He had three milk 
diete, and a pint of milk daily all the time he was in hospital. He states he never 
had plain milk outside hospital, but he has had tea frequently down town. We 
think this case is a probable relapse from last year. We can form no opinion as to 
how or where the disease was contracted. 

6. Private B., F Company, was admitted from No. 4 Boom, Old Floriana, on 
January 23, 1906. He had felt ill for three days. He was employed as company 
cook for two months before he got ill. He drank unboiled goats' milk daily while 
in that employment. Case No. 1, Private P., came from the same company, but 
had no contact with him, and came from another room. This, in our opinion, was 
an almost certain case of milk infection. 

6. Private B., £ Company, was sergeants' mess waiter. He was admitted 
January 81, 1906, and was a relapse case (October 12 to November 18, 1906). 
He lived in No. 8 Boom, B Block, New Floriana Barracks. There was no case 
for four months from the room before his first admission, and none since during 
the year 1906. He was employed as waiter in the sergeanto' mess before and 
after his first attack. States he nerer drank plain goats' milk, only took 
it in his tea. He had to handle goats' milk as a waiter. There is no evidence of 
0ontact. 

7. Private S., D Company (relapse from October 13 to December 9, 1906). 
He came from No. 9 Boom, Old Floriana, and had been in it since his discharge 



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184 Major McCulloch, Major Weir, and Staff-Surgeon Clayton. 

from hospital in December. Stotet he never drank goats' milk except in tea, in 
barracks, and down town. Fri?ate S.'s second admission was on Jannaiy 81, 1906. 
Another man, PriTate B., was adoiitted from this room on April 29, 1906. The 
room had been disinfected in the meantime. Their beds were far apart on oppoaite 
sides of a long room. They were not companions. We can form no opinion how 
S. contracted his disease. 

8. Pfiyate M., C Company, was the third case from this company daring fche 
year. He was admitted February 6, 1906, from Hut 5, Notre Dame. He had not 
been in the same room as either of the two previous cases in bis company. This 
case was a relapse from Korember 26, 1905, to January 22, 1906. He was not 
personally interriewed by us, but we were informed by a man of his company with 
whom he " knocked about " that he drank goats' milk and egg flips frequently 
before his illness. This was a ph>bable milk infection. 

9. Sergeant A., G- Company, the second case from the company, was admitted 
from C Block, New Floriana, where he had a small room to himself. This room 
looked into the goat-frequented ravine at the back of C Block. He had goats' 
milk in tea, and with porridge, at the sergeants' mess. There is no evidence of 
contact. We think this was either a milk infection or a fly infection from goats. 

10. Private M. (see Hospital List No. 4). He came from Boom 5, Old Floriana 
Barracks, and was only nine days in it before his admission to hospital. 

11. Lance-corporal B., E Company, had been at Ghain Tuffieha for 16 days, 
then came to New Floriana, A2 room, whei'C he remained for three days before 
his admission to hospital on March 4, 1906. He was not seen by us personaUy, 
but the colour-sergeant of his company informed us that he frequently drank goats' 
milk. He also had it in tea. He was the only case from Boom A2 during the 
year. He contracted his disease either at Ghain Tuffieha or in Hut 8, Notre 
Dame, in which he had been before he went to Ghain Tuffieha. He ran the risk 
of infection by milk. 

12. Private W., A Company* admitted March 6, 1906, from Boom Al, New 
Floriana; had been at Ghain Tuffieha during the time Lance-corporal B. was 
there, but not in the same tent. W. was an officer's servant, whose master got 
Mediterranean Fever just after his return from Ghain Tuffieha. This man said 
he only drank milk in his tea, but he had tea in the mess, and had access to milk 
there. We think master and man got the disease at the same place, most jffobably 
in the officers' mess. 

18. Private P., F Company (see Hospital List, Case 5). 

14. Private P., B Company, was admitted from No. 6 Hut, Notre Dame, on 
March 16, 1906, having felt ill since February 20, 1906. He had been in Cottonera 
Hospital with gonorrhosa from November 19, 1905, to January 9, 1906. He was 
the first case from his company during the year, and tlie history of the case 
throws no light on its causation. He only had milk in tea, elsewhere than in 
Cottonera HospitaL 

15. Private A, H Company, was admitted from Floriana, New, B4 room, on 
liiaroh 26, after feeling ill for three days. He had been at Ghain Tuffieha from 
February 21 to March 8. He was employed as company cook for six months 
before his illness, and we have positive evidence that he frequently drank goats' 
milk when so employed. There b no evidence of contact. 

16. Private P., A Company, was employed as company cook in the same coc^- 
house as Private A (see above). He was admitted on March 28, after feeling ill 
for two days. He came from Boom 8a, New Floriana, but was admitted from 
Pembroke Camp. He was the first case from the room during the year, and^ 
beside the fact that he worked in the cook-house with Private A., we can find 
no other evidence of contact. Stated he only took milk in his tea, a statement 



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Epidemiological Work in 1906. 185 

-which there it reason to beliere is untrue. We consider these two cases as ahnost 
-oartainlj due to goats* milk. 

17. ^RTate £., F Company (see Hospital List, Case 12). 

18. Prirate L., £ Company, was admitted on April 16, 1906, from a serrant's 
BDom in the officers' mess. He was an officer's servant. He had no known 
-contaet. States he never drank milk except in his tea. He had access to it in the 

mees, and had to handle milk vessels. We consider him a milk infection. 

19. Private 8. H., B Company, Boyal West Kent, was admitted April 17, 1906; 
had no previous illness in Malta, a married man, lived in 11, Floriana married 
•quarters. No milk, except condensed milk, was used in his quart-ers, and he 
stated that he had never tasted goats' milk, even in his tea. His wife confirmed 
his statement. He had eaten no uncooked vegetables or fruit. None of the 
family have been, or are, ill. The quarters were in excellent sanitary condition. 
There is no history of contact. He was occasionally employed on latrine fatigues, 
4sind was so employed about eight weeks before he got ill. We could form no opinion 
-as to the origin of his disease. 

20. Private 8., E Company, admitted April 21, 1906, from Boom 6, Old Floriana 
Barracks. He had been in this room one week, before then he was in Boom 3, 
B Block, New Floriana, where he slept in a bed opposite Private B. (see Case 6, 
4kbove). He had been in hospital— February 1 to February 16, 1906— with 
simple continued fever, and said he never felt well after he came out. He was 
■An officer's servant, and his master. Captain P., got ill soon after his servant. He 

used to drink milk in his master^s quarters. We know that Private 8. and 
Private B. had slept in opposite beds in the same room, before Private 8. got ill, 
but no other relation could be made out between the cases. We think 8. and his 
master are probable milk infections about the same time. 

21. Private F., F Company, was admitted from Pembroke Camp on April 23, 
1906. He had been in Cottonera Hospital with gonorrhoea— October 8 to 
December 6, 1905 — and said he had never felt well since. From Cottonera Hospital 
he went to Boom 4, Old Floriana Barracks, from December 6, 1905, to February 18, 
1906 ; then to Corradino Military Prison to February 18 j then Ghain Tuffieha, 
February 19 to March 3, 1906 ; then Old Floriana, Boom 4, from March 3 to 
March 23; then to Pembroke Camp. Private B. (Case 6 above) came from 
Boom 4 on January 28. He occupied the bed nearly opposite to Private F.'s bed. 
They were not companions, and had nothing to do with each other. F. frequently 
•drank egg flips, which contained goats* milk. On March 81 he had a surfeit 
-cf this drink with a comrade who was '* standing him treat." 

22. Private B., D Company, was admitted from Boom No. 9, Old Floriana, 
■on April 29. He had been employed as company cook for two months before his 
-admission, and used to taste unboiled goats' milk when so employed. Private 8. 

(Case 7 above) came from the same room. They were the only two cases from the 
room during the year. We think this was a milk infection. 

23. Private P., E Company, came from No. 6 Boom, Old Floriana Barracks, and 
was admitted on May 1, 1906. There is no evidence of contact. Private P. was 

-company cook, and states he used to drink goats' milk in the kitchen, where it was 
sterilised, but only after it was boiled. He had no previous illness in Bialta, and 
felt perfectly well until three days before his admission. We think he was a milk 
infection. 

24. Private B., H Company, was admitted from Boom 2 b, New Floriana, on 
May 2, 1906. He had been in this room since March 8, 1906. This was the only 

•oase from the room during the year. He was an officer's servant. 8tates he only 
•drank milk in his tea, but he had access to milk in the mess, where we think he 
«oontraotod his disease. 



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186 Major McCulIoch, Major Weir, and Staflf-Surgeon Clayton. 

26. Private R., C Ck>mpaDj, was admitted from Pembroke Camp— where he had 
been from April 18 until date of admission— April aO, 1906. Before then he had 
been in No. 9, Notre Dame. Date of his admission is shown as May 4, but he was 
a transfer from Forrest on April 30, 1906. He had been company cook since 
December. He said be had drank milk in the cook-house, but once only, during 
the month before his admission. There was no other case from No. 9 Boom, 
Notre Dame, during the year. We think this was a milk infection. 

26. Corporal B., F Company, was admitted from No. 6, B Block, married 
quarters, on May 7, 1906. There were three otlier cases from this family, and all 
within a short interval of time: — 1st. Rose B., aged 8 years, first felt ill on 
April 21, 1906. 2nd. Corporal B., first felt ill April 30. 8rd. OUph B., who first 
felt ill about April 28. 4th. Edith Maud B., who had been ill since about May 9. 
There were three other members of the &mily living in the same quarters — 
Mrs. B., Mabel B., and Ernest B., none of whom, though apparently equally 
exposed to infection, contracted the disease. A son Walter had Mediterranean 
Fever in the summer of 1904, when living with his &ther*s family, and none of the 
rest then contracted the disease. The family then lived in 13, Strada Magaigini. 
The son Walter never lived in their present quarters. They came to their present 
quarters in February, 1906. As the children sickened, they each slept in turn with 
the mother, while Mabel and Ernest slept in the bed with OUph before she was 
known to be ill, and for some time afterwards. Corporal B. slept in Bose's bed, 
when Rose got ill and was put in her mother's bed. The members of the family 
who remained well had at least as close contact with the sick as the sick had with 
each other. The evidence about milk is somewhat conflicting. When the family 
came from Strada Magaizini to their present quarters in February, they changed 
from condensed milk to goats' milk, got from the herd which supplied the West 
Kent Regiment, and which a little later was known to contain infected goats. This 
evidence was got from Mrs. B. at the time a milk census of the married fiamilies 
was made, when as yet no members of the family were ilL Mrs. B. then stated that 
the fiimily had been using goats' milk for two months. When Rose got ill, Mrs. B. 
stated goats' milk was used, but always boiled. When Corporal B. got ill he said 
goats' milk was only used for tea. When OUph got ill, Mrs. B. modified her first 
statement, and said that goats' milk was only taken after Rose got iU. On one 
occasion, when one of us visited the house to get samples of blood, the children, 
during the mother's absence on a visit to the father in hospital, were found having 
tea, and were then using goats' milk. Another child from a quarter on the same 
verandah, who had only recently come out of hospital after an attack of Mediter- 
ranean Fever, was then playing with them. Contact cannot be denied, but : 

(1) None of the family got it when Walter had it in 18, Strada Magaszini; 

(2) Mrs. B. did not get it, though apparently more exposed to infection than any 
other member of the &mily, through sleeping with infected children ; (8) Neither 
Mabel nor Ernest got the disease after having slept with OUph before and after she 
got ill. The history iUustrates the difficulty of obtaining a^urate information 
about the use of milk. The obvious deduction, we think, where goats' milk oomes 
into a house, whether stated to be used only for tea, or boiled, is to look on it with 
equal suspicion as though stated to have been used unboiled. We think the weight 
of evidence points to this outbreak having been due to the use of infected goats^ 
milk. 

27. Private B., F Company, was admitted on May 29 from Room 8, Old Floriana, 
where he had been for two months before his illness, after feeling ill for two days. 
Two other cases had come from this room during this year (Oases 18 and 17 aboTe)» 
but on both those occasions the room had been evacuated and lime-washed, eto. 
B.'s bed was on the opposite side of the room to those of the other two oases. Th* 



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Spidemioloffical Work in 1906. 1S7 

history of this case throws no light on its causation. We believe it was possibly 
caused by infected flies. He had milk in his tea. 

28. Private J., D Company, was company cook in Old Flonana cook-house for 
14 months. He had no previous illness. He was admitted on May 22 from 
Room 10, Old Floriana Barracks, from which there had been no previous case 
during the year. He used to drink a pint of unboiled goats' milk daily. The 
herd which supplied this milk was foimd about this time to contain 11 infected 
goats. 

29. Private K., G Company, came from 3c Room, New Floriana, and was 
admitted May 23, 1906. Says he only had milk in his tea. The history throws 
no Ught on the causation of the disease. C Block was much exposed to flies from 
herds of goats which sheltered at the back of the quarters. There is no evidence 
of contact, and no other case came from the room. 

30. Private H. belonged to the same company as the last case, and came from the 
room underneath the one Private K. had come from. He was admitted two days 
later than Private K., i.e., May 26, 1906. Private H., too, only had milk in his tea. 
We beUeve these two cases were probably fly infections from the goats which 
sheltered near the barracks. 

31. Private H., A Company, was admitted on June 6 ; his blood reacted on the 
same day. He began to feel ill on June 2. He had been in 4 Room, A Block, 
New Floriana, for seven weeks before his admission. Before then he had done 
a short period of duty in the Military Police, and lived in 33 Hut, Tigne. He then 
did clerk's work in the regimental pay office, then ordinary duties, and at the time 
he went sick was doing a course of gymnasium. He only had milk in tea (and that 
condensed milk) since May 15. He never had food out of barracks. He had spring 
onions and cheese for supper frequently. There were two other oases from Hut 
No. 33, Tigne, during the year. This was the poUce hut, and the occupants were 
constantly changing. The two other cases were a soldier of the 2nd Fssex 
Regiment, who was admitted on May 7, and a soldier of the 4th Rifle Brigade, who 
WAB admitted on May 21. These three men were in 33 Hut, Tigne, together, but 
they were not even acquainted with each other, and their beds were in different 
parts of the room. The room. No. 10, Old Floriana, from which Private H. was 
admitted to hospital had been occupied by Private J. (Case 28), but it is quite 
certain that Private H. did not contract his disease in No. 10 Room. He was feeling 
ill when he went to it, and was only in it two days. We can form no opinion 
as to the origin of this case, and do not think known contact can explain it. 

32. Private I., Gt Company, was admitted from Ghain Tuffieha on June 6. 
He had been cook in the sergeants' mess since April 21, 1906. Said he only 
felt ill for three days before he went sick, but possibly was not feeling too well 
before then, as, having been a moderate drinker, he had become a teetotaler about 
three weeks. Before he went to Ghain Tuffieha he was employed as a company 
cook in Floriana Barracks, and he then drank goats' milk. He lived in Room 1, 
C Block, New Floriana, a room which looks into the goat-frequented ravine, which 
we have mentioned before. The cook-house at Ghain Tuffieha, when we visited 
it, was swarming with flies. Goats' milk was said not to be used in this cook- 
house. A large number of the ponies at Ghain Tuffieha were found to react to 
Micrococcus melitetiHs. The case was either a case of fly infection at Ghain 
Tuffieha or, as we think more probable, was contracted when he was cook at 
Floriana Barracks, and that the case, like many, is merely one of long latency. 

33. Quartermaster-Sergeant C, D Company, was admitted on June 12, 1906, 
from 24, A Block, Married Quarters, Misida Bastion. His wife, an almost certain 
mUk infection, had been admitted on May 7 with the same disease. Quartermaster- 
Sergeant C, and his wife, got ill about the same time. Mrs. C. drank goats' milk 



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188 Major McCuUoch, Major Weir, and Staflf-Siirgeoii Clayton. 

freely, but said it was always boiled. Mr. G. said it was generally boiled, and he 
used-it only for tea. Two boys, Stephen and John, never drank milk, and remained 
Apparently quite well, though the blood of both boys gave a good positive reaction 
to Microcoecu8 tnelitenns. They were both strong, active lads, who on many 
occasions showed us round different places near these married quarters. They 
remained well all the season, and took hard exercise daily. We think the whole 
family were infected at the same time, and that the agent was infected goats' milk. 
There is no evidence of contact except among the members of the family. Husband 
and wife occupied one room, the boys another. The urines of both boys were 
•examined on several occasions, with negative results. 

84. Private S., B Company. 

36. Private H. H., Company. 

36. Private K., C. Company. 

87. Private H. W. »., C Company. 

The four cases above are important from the point of view of place infeotion. 
Case 86 we think to be a probable case of milk infection. In the other three 
<»8e8 we have been unable to obtain any history of milk drinking. From the 
point of view of place infection they must all be considered together. Private S. 
bad no previous illness in Malta. He first felt ill on Jtme 11, with giddiness, and 
was admitted to hospital on June 14, 1906. His blood reacted on the same day. 
He was probably ill longer than he said, as, having been a great cigarette smoker, 
he had given it up entirely a fortnight before he went sick. He had never drunk 
goats' milk, and since May 15 only had condensed milk in his tea. There is 
nothing in his dietary or manner of life to suggest a clue to the probable source of 
his illness. He was admitted from Boom 6, Xotre Dame, but had been in it only 
Binoe June 5, ten days before his admission, and six days before he felt ill. Before 
June 5 he had lived for over two months in Room No. 8, Old Floriana Barracks. 
He was the first case this year which occurred in Boom 8, and it is quite clear that 
the case belongs to No. 8 Boom rather than to Boom 6, Notre Dame. It was noticed 
At this time how numerous the flies were in Floriana Barracks, and it was now that 
we visited the Civil Hospital, and found it very full of flies also. It was suggested 
that the windows of the hospital should be made fly-proof. The suggestion, though 
well received, had not materialised at the date when Old Floriana Barracks were 
•evacuated. From S.'s history, it is seen that he sickened nine days, or less, after he 
left No. 8 Boom, Old Floriana. Private H. H. (Case 85), the second case of the 
group, had been in No. 4 Boom, Notre Dame, for more than two months until 
Jime 6, the same day on which Private S. left it. S.'s bed in Boom 8 was No. 5, 
right. Private H. H.'s bed in Boom 8 was No. 7 on the right. It is quite clear 
that S.'s illness was due to no contact with H. Whether H.'s illness had any 
connection with 3., or Boom 8, remains to be examined. H. H. came to Boom 8 
on the day S. left it. H. slept in a bed very close to the one S. had left, possibly 
the same bed. Neither bed nor room had been disinfected. S. was not ill when 
he left No. 8 Boom. Here, apparently, are the elements of a pretty example of 
mediate contagion or place infection. Though S.'s case might explain H. H.'s and 
the other two cases, yet the converse does not hold good. Private H. H. came 
from No. 6 Boom, Notre Dame, on June 5, to No. 8 Boom, Old Floriana Barracks. 
His history, which follows, shows that he most probably had the disease when he 
came to No. 8 Boom. He was admitted into hospital on June 15, and his blood 
reacted on the same day. If he contracted his disease in Boom 8, t.e., if the same 
cause operated in H.'s case as in S.'s, then H.'s case must be one of ten days' 
incubation exactly, at the extreme limit; but H. manifested almost the only 
symptom of his illness on June 11. Therefore the incubation period is reduced 
to seven days, t.«., from June 5 to June 11. H. began to suffer from pains in the 



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Ej)idemiologic(d Work in 1906. 189 

kneee on June 11, and had no other symptom, except rise of temperature, through 
the TThole coarse of his attack. He nerer felt sick or lost his appetite. For a 
fortnight at the beginning of May he was on barrack hospital treatment for exaotlj' 
the same kind of pains in his knees as caused him to go sick in June. At that. 
time his temperature was not taken. He then was in No. 6, Notre Dame,, 
and had been for two months. He had been an officer's serrant until Maj 2,. 
and, his master going on leare, he then returned to ordinary duty. He had a- 
relapse in September. Thinking he might have been an ambulatory case, and 
excreting Micrococcus melitentia in his urine, we had it examined on several 
occasions, always with negative results. The history of this case makes it clear 
that Private H. H., when he came to Boom 8, Old Floriana, was already the yictim 
of a mild attack of Mediterranean Fever, and consequently had no connection with 
Private S. or Room 8. 

The next case. Private K., No. 36, had been in Cottonera Hospital from May 30, 
to June 11, 1906, suffering from synovitis. He was admitted on that occasion from 
Boom No. 8, Notre Dame, and therefore, so far as place is concerned, had as yet 
no connection with either H. or S. He had been in No. 8, Notre Dame, for two 
months. He came to No. 8 Boom, Old Floriana, on the evening of June 11, and 
occupied the bed next to H.'s. He felt quite well on discharge from Cottonera, 
and remained so until Jime 18, when he had headache which continued, and he 
waa admitted to hospital on June 21, and on the same day his blood reacted. If 
he got ill in No. 8, Old Floriana, he must haye got his disease between Jirne 11 
and 17, on which date Boom 8 viras evacuated for disinfection, and all the occupants 
were put in tents on the roof. He must, therefore, have contracted the disease in 
six days, quite possible, but in his case highly improbable. His blood reacted on 
June 21, and the case was a mild one. Cases caused by direct inoculation, aa 
a rule, are severe, and unless this was one, his blood would hardly have reacted 
within eight days of his getting the poison, and he would not have manifested 
symptoms within six days. The synovitb, too, from which he suffered in May» 
is suggestiye. Though the possibility of direct inoculation in Boom 8, Old Floriana^ 
must be allowed, the history of the case makes it more than probable that 
Priyate K. contracted his disease elsewhere. We have but little evidence on which 
to base an opinion as to where he did contract his disease, but on asking him if he 
ever drank goato' milk in any form, he stoutly denied eyer having done so» 
forgetting that he had already told us, when we examined all the men in the 
company as to whether they took milk, that he frequently drank egg flips, one 
of the ingredients of which was unboiled goats' milk } he then also stated that he 
drank rum and milk, a fairly common drink among soldiers in Malta. 

Case No. 87, that of Private W. J. H., brother of H. H. (Case 36), must now be 
considered. Private W. J. H. had been employed for seven months in the Military 
Police, during which time he lived in 1a Block, New Floriana. Fourteen daya 
before his admission to hospital he became an officer's servant, and on June 12 he 
went to live in No. 8 Boom, Old Floriana. He left this room and went into a tent 
on the roof, as did the other occupants on June 17. He was therefore only exposed 
to the presumed malign influence of Boom 8 for five days, from June 12 to 17. 
His blood, in common with those of 23 other men, contacto of the previous cases,. 
was examined, and being found to react, and having a slight rise in temperature^ 
he was sent to hospital on June 22 for Mediterranean Fever. In hospital he never 
felt iU, and did not believe there was anything the matter vrith him. None of the 
bloods of the other contacts reacted. If W. J. H. contracted his disease in No. 8 
Boom, he must have done so between June 12 and June 17, i.«., in four days. Hia 
blood, taken on June 19, was reported to react, and again on the 2drd. As he 
never felt ill, it is difficult to decide when he got his disease. From June 12 to 1^ 



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190 Major McCulloch, Major Weir, and Stafif-Surgeon Clayton. 

(date of his first reaction) ib onlj seren dajs, but all which can be granted if he 
oontnicted his disease in Ko. 8, Old Floriana. 

These four cases have been reidewed at great length because they seemed at 
first to furnish a good example of contact or place infection, but careful examination 
of each case seems to negatiye that Tiew. It is certain that H. H. did not contract 
his disease in Boom 8, and the eridence is almost equally strong against Prirate E. 
ha-ring got ill there. Thus an apparently strong case for contact becomes a 
decidedly weak one. We conclude that PriTate S. contracted his disease when 
liTing in No. 8 Room, Old Floriana, and think that flies aro a quite probable 
explanation of his case. We think Private H. H. contracted his disease while 
living in Boom 4, Notre Dame, before the beginning of May, when he was an 
officer's servant. He denied drinking milk or eating uncooked vegeti^les. Hid 
occupation is suggestive. Private K. contracted his disease while living in Boom 
No. 8, Notre Dame, and he is a possible case of milk infection by egg flips and rum 
and milk. Private W. J. H. was a pal of Private K., and used to knock about 
with him. He may have contracted his disease in the same place as Private K. 
Information from the colour-sergeant of his company was obtained to the ettect 
that these three men used to frequent a public-house, paying attention to the same 
barmaid, and where they had egg flips. It is therefore possible that this was 
a common source of infection. 

88. Private J., Company, was admitted on June 26, 1906. His blood reacted 
next day. He came from No. 7 Boom, Old Floriana Barracks, where he had* lived 
since June 16. Up to then he had been caretaker and sole occupant of Yittoriosa 
Barracks from May 5. Before then he was in No. lO Boom, Notre Dame. He first 
felt ill vrith headache and faintness on June 16, when shifting his kit from Yittoriosa 
Barracks. He says he had been perfectly well until then. Neither his manner 
of life nor his diet suggest any clue to the source of his illness. At Yittoriosa 
he lived in the guard-room, a dark and mouldy, ill- ventilated building. Most 
of the ventilating shafts to the sewers are broken just above the ground level, and 
at times emit foul odours. He had his meals with a detachment of the 4th Bifle 
Brigade in Yerdalla Barracks. There is no evidence of contact or of his ever 
having drunk goats' milk. 

89. Oorporal T., F Company, a relapse from September 4 to November 27, 1905. 
He was re-admitted on June 27 from New Floriana Barracks, where he had been 
for three days. Before then he had been in a tent on the roof of Old Floriana 
Barracks since May 5. His urine was examined to see if he was excreting 
Micrococcus melitetmi, Besult negative. He states he only drank milk in his tea, 
and that his first attack was contracted at Pembroke Camp, where he was in charge 
of the camp latrines. 

40. Private S., A Company, was admitted June 80 from 2b Block, New Floriana, 
where he had been for three weeks. Before then he had been in Boom 4, Old 
Floriana. He had had slight fever and pains at the beginning of April. These 
pains got worse through bathing, and he got headache about June 24. He had been 
in Boom 4, Old Floriana, for over six weeks, and he probably was iU since ApriL 
He was an officer's servant, and had goats' milk in tea at the mess ; he says he 
never drank it plain. We think he contracted his disease in the officer's mess 
before goats' milk was stopped there. 

41. Lance.Corporal B., A Company, was admitted from No. 9 Boom, Old Floriana, 
on Jidy 9. He had been in this room for two months. He was admitted for 
gonorrhoea, and his disease was changed to Mediterranean Fever on August 8, 1906. 
He contracted gonorrhoea on June 80. He used to drink goats' milk up to the 
middle of June. His first symptoms of illness began on July 16, vrith double 
sciatic pains. These pains persisting, and he having fever, his blood was examined. 



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Epidemiological Work in 1906. 191 

and found to react on August 2, 1906. There was no historj of contact. He 
either contracted his disease where he got gonorrhoea or else when he drank milk, 
which he did freely until the middle of June. He also drank egg flips frequently. 

42. PriTate B., F Ck)mpany, first fell ill on August 6, 1906, with headache, 
' haokaohe, and giddiness. He was admitted on August 7, and his blood reacted 
on the same date. He had been in Ko. 17 Hut, Manoel, since July 11, 1906. 
Before then he was in a small room on the ground floor of Block B, New Floriana 
Barracks. He had this room to himself, and was in it since the beginning of May. 
In June (June 28 to July 2, 1906) he was in Cottonera Hospital, with inflammation 
of oonneotiTe tissue, the result of scratching his arms, which had been severely bitten 
by sand fliee. He then had slight fever, but felt perfectly fit during the interval 
between his discharge and readmission. He never drank goats' milk, and there 
is no evidence of contact. There had been no other case in any room in which he 
Hved during the year. He used to have uncooked tomatoes for his supper 
frequently. He visited a brothel July 19, 1906. No venereal disease resulted. 

48. Private H., September 1, 1906, relapse. (See Case 35.) 

44. Private S., F Company, was admitted from Salvatore Counter-guard where 
he had been for the past eight months. He was admitted on September 12. The 
man was a signaller. The history of the case throws no light on its causation. 
This was the only case from the counter-guard during the year. The men in 
the oounter-guard were living quite apart from the rest of the regiment. 

The distribution by companies was as follows : — 



A Company 


6 cases. 


B „ 


... 4 ,. 


c „ 


9 „ (including four relapses). 


D „ 


.. 4 „ 


E „ 


.. 4 „ 


F „ 


.. 10 cases (including one relapse), one married 




man and one man from Salvatore Counter- 




guard. 


a „ 


5 cases. 


H „ 


... 2 „ 



The spot map shows the barracks from which each case came. 

We consider that 28 of the above cases were most probably milk 
infections, while all, with a few exceptions, are possible milk 
infections. 

By barracks the distribution was : — 
Old Floriana Barracks ... 14 cases. 



New Floriana „ 
Notre Dame 
Salvatore Counter-guard 
Other places 



14 

8 

1 
7 



A careful analysis of the cases occurring in the several companies 
and in the various parts of barracks was made, and we were unable to 
discover any particular persistence of the disease in any company or in 
any particular part of the barracks. 



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192 Major McCulloch, Major Weir, and Staff-Surgeon Clayton. 

The most striking fact about the history of this regiment is that in 
the first six months of the year forty cases occurred, whereas, for the- 
remaining four months of the battalion's stay in Malta, the months* 
which usually are marked by special prevalence of Mediterranean 
Fever, there were only four admissions. Of these, one was a pelapse, 
and the second was that of a case in which there is a definite history of 
goats' milk drinking. The first six months was the period marked 
by the use of goats' milk ; the second represents the period in which 
condensed milk was in use. 

Series 2. — The Cases in the Royal Army Medical Corps. 

1. Priyate H. was admitted to Valletta Hospital for Mediterranean "Ferer on 
January 12, 1906. He had been employed as a nursing orderly on night duty in 
the Mediterranean Fever wards. His previous hospital entries are simple continued 
fever September 15 to September 22, 1906, VaUetta Hospital ; he then had foui^ 
milk diets and 16 pints of extra milk. Again, simple continued fever October 9 to 
October 17, 1906, VaUetta Hospital, where he had six milk diets and 11 pints of extra 
milk. Again, caries of dentine November 28 to November 29, 1906, VaUetta Hospital, 
when he had five milk diets and 7 pints extra milk. Admitted for Mediterranean 
Fever January 12, 1906, and had been feeling unweU since January 1. This case- 
was certainly contracted in the hospital either as a patient or when doing nursing 
duties. It seems to be a 1906 case, and not having examined the man personaUy, 
we think that the information avaUable makes it possible that the case was due to 
hospital milk. 

2. Lance-Corporal B. — Admitted January 17, 1906, for Mediterranean Fever^ 
He was employed working the steam disinfector at Cottonera Hospital, and ir 
believed to have contracted the disease through handling soiled bed linen. We know 
nothing about his drinking milk beyond the fact that goats' milk was then in use 
at the hospital. From what we know, infected clothing seems the most probable 
source of his illness. 

8. Private Y. — Admitted January 22, 1906, for Mediterranean Fever. He had 
been detachment mess orderly for the Royal Army Medical Corps, employed at 
Cottonera Hospital, for three months before he got iU. He is noted as being 
habitually careless. There is no evidence of contact with Mediterranean Fever 
patients. Goats' milk was in use in detachment mess. In the absence of other 
information, he is a possible case of milk infection. 

4. Corporal W.— Admitted February 16, 1906. First felt iU, February 1, 1906. 
Employed at Forrest Hospital since December 8, 1906, in charge of disinfection, 
duties. Is supposed to have contracted his disease through handling infected 
clothing. Nothing known about his drinking milk. Goats' nulk was then used at 
Forrest Hospital. 

6. Private P. — Admitted February 16, 1906. Has had pains since January 16,. 
but has never felt reaUy well since attack of simple continued fever in July and 
August, 1906. He had some teeth extracted in December last, and was then a 
patient in hospital from November 28 to December 8, 1906, and had two days' plain 
milk diet when teeth were extracted, otherwise states he only had milk in tea. He 
was employed at VaUetta as nursing orderly in Mediterranean Fever wards, and did 
night duty, and had to handle vessels containing stools and urine of Mediterranean 
Fever patients. Said he was always very careful about personal disinfection. This- 
man was evidently iU since January 1, and may possibly be a milk infection. The 
case was contracted in VaUetta HospitaL 



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Epidemiological Work in 1906. 193 

6. Private L.— Admitted February 28, 1906, after feeling ill for three days. Had 
-eimple continued ferer in August, 1906. Was employed as nursing orderly in 
Mediterranean Ferer ward at Valletta. This man states that he frequently drank 
gostB* milk with soda water. He used to get it at the canteen. Does not know 
whether boiled or not. Tliis man is a quite possible milk infection. 

7. Lance-Corporal P.— Admitted March 12. Had been employed in the Mediter- 
ranean Fever Commission laboratory when experimental work was being tried there 
with infected dust. He almost certainly was a case of laboratory infection. He 
drank goats* milk in tea only. He thinks infected dust was the cause of his illness. 

8. Priyate B. — Admitted April 1. Was employed in enteric and Mediterranean 
Fever wards, Valletta. Had no previous admissions in Malta. Went for duty to 
Imtarfa on March 17, and first felt ill on March 29. Had much handling of 
bedding and bed-pans and urinals of Mediterranean Fever cases ; was in the habit 
of drinking goats' milk unboiled freely at the house of a civilian friend, an almost 
daily habit until the time of illness. This is a very possible case of milk infection. 

9. Private C. — Admitted April 8, 1906, had no previous admissions. Employed 
•on general duty in Cottonera Hospital. Had little or no direct contact with 
Mediterranean Fever oases. This man said that he frequently took both boiled and 
unboiled goats' milk, and that be took it in large quantities. He also informed us 
that many Boyal Army Medical Corps men did the same. He attributed his illness 
to a wound of the hand caused by a splinter when scrubbing the floor in 
No. 6 Ward, Cottonera Hospital. He often took tea in Valletta tea shops. This is 
» quite possible case of milk infection. 

10. Corporal F.— Admitted April 8, 1906, after feeUng ill for four days. 
Employed as store-keeper, and had much handling of infected linen, etc. Was 
seldom or never in the Mediterranean Fever wards. This man states that he never 
•drank goats' milk even in tea. MUk seems out of the question in this case. 

11. Corporal B. — ^Admitted May 1, 1906, after feeling ill for three weeks. Has 
no previous hospital entries. Was employed at Forrest Hospital as assistant waid 
master, pack store keeper, and in charge of bedding. He had to steep the linen of 
patients in carbolic lotion before its removal to Cottonera Hospital for steam disin- 
-fection, but had not much of that class of work at Forrest Hospital, and little or no 
-contact with Mediterranean Fever cases. Drank soda water and goats' milk daily. 
This man's wife got Mediterranean Fever shortly after her husband's admission. 
They lived in quarters (the caretaker's house, Spinola Batteiy), some distance from 
Forrest Hospital. Mrs. B. states that she, too, drank soda water and goats' milk, 
but that she always boiled the milk for her husband and herself. There are 
•excellent grounds for believing that this house was not very carefully managed, and 
though her statement may be in the main true, as she is careless in other matters 
Mhe is not likely to have been careful in the matter of milk boiling. These cases are 
both possible oases of milk infection ; indeed, we believe milk to be tbe most Ukely 
.source. 

12. Private M. — Admitted for Mediterranean Fever on May 9. He had been 
•employed in the general duty section at Valletta Hospital, and just before his 
^idmission was employed window cleaning in the long ward, Valletta Hospital, at the 
time a general disinfection of this ward took place. He attributes his illness to 
this cause. The medical history of the case, however, suggests that this cause had 
jiotbing to do with the case, and it is quite likely that he contracted his disease in 
1905. He had oflbred himself for protective inoculation, and on examining his 
blood before this was done it was found to give a positive reaction to Micrococcus 
melitensis. This was on April 25, 1906. In consequence of the reaction he was not 
inoculated. His medical history is as follows : Sprain (right ankle), December 20 
to December 23, 1905, no definite cause; sprain (right knee), February 21 to 

(2089) 



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194 Major McCulloch, Major Weir, and StaflF-Surgeon Clayton. 

February 26, 1906. Rheumatism, March 24 to March 27, 1906; rheumatism, 
March 28 to March 29, 1906. Colic, April 28 to April dO, 1906. He Bays he only 
had goatfl' milk in tea, and also in hospital as a diet when he had colic and on the- 
prerious occasions. He had no direct contact with patients, but had to clean the 
seats of No. 87 latrine and oil the urinaL It is difficult to belicFe that the dusting 
of the windows in the long ward in April had anything to say to this man's iUness. 
The source of infection is not known, but it is a possible milk infection. 

18. Private B. — Admitted on May 18, after three days* illness, and had no 
previous illness in Malta. Has been lunatic attendant at Cottonera Hospital since 
arrival in Malta (October 8, 1904). He had cut the hair of a few patients who had 
Mediterranean Fever, the last time he did so being April 25, 1906. He slept in a 
bunk by himself. Stated he only had goats' milk in his tea, and about twice » 
month with porridge ; the last time he had porridge and milk was about April 21. 
He thinks he contracted his disease through cutting the hair of Mediterranean 
Fever patients. This is a possible milk infection. 

14. Corporal &. — Admitted May 18, 1906, after feeling really ill since the middle 
of April, but had no previous admission. He was clerk in the office at Cottonera 
Hospital. He never went into the Mediterranean Fever wards, but used to send oflT 
the blood pipettes containing the blood of cases for examination. He stated that 
sometimes a tube was open, and that blood may have got on his liands. He slept 
in a hunk by himself, and had his meals at the sergeants' mess, where each man 
puts the milk into his own tea, i.e., milk and tea not in bulk. He stated that he 
had never taken goats' milk neat. He used to have tea and coffee in a tea-house,. 
Valletta, occasionally. €k)ats* milk is as probable a source as any other in this case. 

15. Private S.— Admitted May 25, 1906, after feeling ill for five days. Employed 
at Valletta Hospital in general duty section. His principal duties were spraying the 
rooms and beds of patients who bad been removed to hospital with Mediterranean 
Fever, and superintending the milking of the goats at Valetta Hospital. M. (case 12) 
had slept in the bed next to his bed, but not for a fortnight before M. went 
sick. Interval between April 26 to May 25. Says he only had goats' milk in tea. 
in hospital, but used to have egg flips freely on Saturday niglits ; last occasion 
May 12, 1906. These egg flips were got at the Bound House, Strada Beale, and 
contained goats' milk. This is a possible case of infection through milk. 

16. Private J. — Admitted June 19, 1906. Employed as sergeants' mess waiter at 
Valletta Hospital, and had been ill since June 11, 1906. He had milk in tea until 
May 21, and drank unboiled goats' milk about a fortnight before that date. He 
had access to milk in the sergeants' mess. There is no history of contact, and no 
previous illness in Malta. 

17. Lance-Corporal J. — Admitted September 2, but ill since Augrust 1, or 
probably longer. He worked all the season in the Commission laboratory, and had 
to handle many infected animals. He had been twice inoculated against Mediter^ 
ranean Fever. Milk in tea only. Is an almost certain laboratory infection. 

18. Private B. — Had been in Gozo for two years and nine months, before which 
period he had had simple continued fever for 22 days in Valletta Hospital (October 5 
to October 27, 1903), on which occasion he was ill for three weeks before he went sick. 
He returned from Gozo on March 19, 1906. He was twice inoculated against 
Mediterranean Fever this year, on April 26 and on May 10, 1906. He was a 
patient in Valletta Hospital from May 30 to June 6 with dyspepsia, and again with 
debility September 8 to September 15, and on September 16 disease was changed to 
Mediterranean Fever. He had been feeling ill since May 15 with pains in different 
parts of his body and limbs. His duties after his return from Gozo were four days' 
gate duty, then washing floors and windows and woodwork of 20a Ward after it 
had been disinfected and colourwashed in April, after which he was taking bed oota 



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Epidemiological Work in 1906. 195 

to pieces, and oiling and cleaning them. This work took about 14 days. After this, 
did 28 days' night duty in Mediterranean FeTer ward. Next had an admission 
to hospital as above. When discharged had 14 days on gate duty ; after that did 
general duty fatigues up to the time he went sick, on account of increasing pains. 
This man states that he only drank milk in his tea. The beginning of his illness 
is quite uncertain. He may possibly haye had a mild attack of Malta Fever before 
he went to Gozo, and he seems to have got his present attack about May this year. 
It is a possible milk case. 

From the histories of the above cases it is seen that their employ- 
ments were as follows : — 

Five men were employed as nurses of Mediterranean Fever patients. 
Two were in charge of the steam disinfector for the disinfection of 
linen, bedding, clothing, etc., of Mediterranean Fever patients. One 
was the detachment mess orderly at Valletta Hospital, and had 
no contact with Mediterranean Fever cases. Two were attendants in 
the laboratory of the Mediterranean Fever Commission. Three men 
were employed in the general duty section of the Eoyal Army Medical 
Corps, and had very little to do with Mediterranean Fever cases 
directly or indirectly. One man was hospital store-keeper, and had to 
handle infected linen. One was assistant ward master at Forrest 
Efospital ; he had little to do with Mediterranean Fever cases. One 
was a lunatic attendant (no contact). One was a clerk in the office at 
Cottonera Hospital (no contact). One man was sergeants' mess waiter 
(no contact). 

Of the whole series, in three cases only is it possible to exclude 
goats' milk as a possible factor in the causation of the disease. Six 
cases in our opinion were most probably due to milk infection. 

Series 3. — Hospital Cases. 

Of cases which we think were contracted in hospital, other than 
men of the Royal Army Medical Corps, there are 23, or 14*5 per 
cent, of all the cases to the end of November. None of these 
presumed hospital infections took place later than June 11, and 
the case diagnosed on that date was that of Quartermaster- 
Sergeant W., Eoyal Engineers, who had been in Valletta Hospital 
since February 27, with enteric fever. He was a married man 
and lived in the married quarters, St. George's Barracks. His wife 
did not contract the disease. He had no contact with Mediterranean 
Fever patients. We think his illness was most probably due to 
milk infection while a patient in hospital. The last case before 
Quartermaster-Sergeant W.'s was admitted on May 30. 1 1 is thus 
evident that all the possible hospital infections during the year 
occurred within a period of 15 days after the use of goats' milk was 
stopped in the military hospitals. 

(2089) 2 



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196 Major McCulloch, Major Weir, and Staff-Surgeon Clayton. 

The history of the remaining 22 cases is given below : — 

1. Priyate L., Bojal West Kent Begiment, was inFalided before we arrived in 
Malta. He was admitted from Boom 4, Block G, New Floriana Barracks, the only 
case durlpg the year from the room, on Norember 11, 1905, to Cottonera Hospital, 
with simple continued fever, and was transferred to Citta Vecchia on December 
24, 1905. He was on milk at Cottonera from November 14 to the end of the 
month, and at Citta Vecchia he had milk from January 2. His blood reacted to 
the Micrococcus melUenHs on January 14, 21 days after his transfer from Cottonera. 
He seems to have contracted his disease at Citta Vecchia, and is a possible case of 
milk infection. 

2. Q-unner P. was admitted into hospital on January 8, 1906, from Hut 80, 
Tigne, from which hut there were no other cases during the year. He was admitted 
with gonorrhoBa. His disease was changed to Mediterranean Fever on January 80, 
1906, and his blood reacted on Januaiy 81. He had been feeling ill for a week. 
He had two days on milk on his admission. He stated that he often drank soda 
and milk at different houses in Sliema and Valletta. 

8 Bombardier S., Boyal Qarrison Artillery, had been in Tigne, Block A, Boom 1, 
and from there was admitted to Valletta Hospital, with psoriasis, on October 17 
to December 6, 1905. From Valletta he was transferred to Citta Vecohia Sana- 
torium from December 7 to February 8, 1906. He was diagnosed as Mediterranean 
Fever on February 10, 1906, after feeling ill for four days. His blood reacted on 
February 10. This was his first illness in Malta. The disease was contracted at 
Citta Vecchia, where he had milk (extra) every day from his admission. He had 
possible contact with convalescent patients in Citta Vecchia, but no direct relations 
with them. 

4. Private M., 1st Boyal West Kent. The history is curious. Private M. was in 
Cottonera Hospital from August 29 to November 28, 1905, with gonorrhcsa. On 
discharge from hospital, he went to No. 5 Hut, Notre Dame, where he lived for 
iire days, and then embarked for England, time expired, on December 8, 1905. He 
remained in England, perfectly well, until February 10, 1906, and then, having 
rejoined, embarked for Malta, where he arrived on February 19, 1906. When 
marching up to barracks from the ship, he got drenched with rain (February 19, 
1906, was a day of heavy rainfall — 1''*948 — for Bialta), and next day he felt sUif 
and ill, with pain in the left shoulder and a feeling of malaise. This pain got worse, 
and on February 27 he was admitted to Valletta Hospital, where he was found to 
have fever. EEis blood reacted on March 4, 18 days after he reached Malta. 
The time is long enough for a man to get Malta Fever, but this man was perfectly 
certain that on February 20 he had all the symptoms for which he was admitted 
to hospital on February 27. He had a first-lass memory, and told all the dates 
without pause, which were subsequently verified by reference to official documents. 
Where or when did he contract his disease? We think he contracted it in 
Cottonera Hospital before his departure for England, otherwise he began to 
manifest the symptoms of it on the day after his return to Malta. 

5. Private P., 1st Boyal West Kent, was admitted to Valletta Hospital, after 
feeling ill for five days, on March 12, 1906. He had been in Boom 88, Old 
Floriana Barracks, for 89 days, before which he had been in Valletta Hospital with 
gonorrhoea, and had had milk during that admission. He is a probable hospital 
case, otherwise he may have contracted his disease when he got his gonorrhosa. 

6. Q^unner B. This man was stationed in Fort Bicasoli since his arrival in 
Malta. He had been in Boom 2 for four months, and was the only case from 
the room this year. He had been in Cottonera Hospital from February 15 to 
February 23, 1906, with an abscess in the hand and, on discharge, returned to 
Bicasoli, which he hardly ever left in the interval between discharge and 



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Epidemiological Work in 1906. 197 

readmisaion, as he " folt weak." He got leg painn and headache on March 16, and 
was admitted with Mediterranean Ferer on March 21, and his blood reacted on 
March 26. This man used to frequent both public-houses and tea-shops before 
his first admission to Cottonera. It is probable that he contracted his disease 
in Oottonera Hospital, or in some of his Valletta haunts. He had seyeral dajs' 
milk diet in Cottonera on his first admission, and he also used to have tea 
frequently in Valletta tea-shops. 

7. Trumpeter S., 100th Company, Boyal €kurrison Artillery, was admitted into 
hospital, March 28, 1906, and was found to be suffering from Mediterranean Ferer. 
Blood reacted April 2, 1906. He had been feeling ill, t.0., tired and had headache 
frequently, and pains in arms and legs, and poor appetite, for about two months 
before his admission, that is to say, he felt ill from the first week in Februaiy. 
He had been in Cottonera Hospital — NoTember 16 to December 6, 1906 — with 
gonorrhcea, and had had milk in hospital. He said he had never had food out 
of barracks, and then only barrack rations and tea (condensed milk). He ate no 
uncooked Tegetables or fruit. He spent a few days in No. 11 Room, Bicasoli, before 
his admission, from which room Bombardier 0. was admitted for Mediterranean 
Fever on March 1, 1906. Trumpeter S. obviously did not contract his disease in 
No. 11 Room, as he had been feeling ill a long time before he went into it. If he 
contracted his disease in Bicasoli it was in Boom No. 6, where he lived from the 
time of his discharge from Cottonera until his readmission for Mediterranean 
Fever. 

It may be remarked here that five oases out of eight, admitted for Mediterranean 
Fever in 1906, had all been in Cottonera Hospital at or about the same time, 
suffering from other complaints, and were readmitted with fever within two months 
of their discharge, t.e., the following cases : — 

G-unner R. — Cottonera Hospital, for soft chancre, September 26 to December 9, 
1906, during which time he had some fever, but his blood did not react. He was 
readmitted with Mediterranean Fever January 21, 1906. Interval between 
discharge and readmission, 48 days. 

Gunner L. — Cottonera Hospital, for inflammation of lymph glands, October 22 to 
November 20, 1906, was then transferred to Citta Vecchia Sanatorium from 
November 21 to December 19, 1906, and was readmitted for Mediterranean Fever 
January 26, 1906. Interval between discharge and readmission, 87 days. 

Q-unner D. — Cottonera Hospital, for soft chancre, October 31 to November 28j 
1906, and was readmitted January 17, 1906, with Mediterranean Fever. Interval 
between discharge and readmission, 60 days. 

Gunner K. — Cottonera Hospital, for gonorrhosa, November 21 to December 6, 
1906, and was readmitted for gonorrhoea January 16, 1906, and his blood reacted to 
Micrococcus melitenns January 18, 1906. Interval, 41 days. 

Trumpeter S. — Cottonera Hospital, for gonorrhoea, from November 16 to 
December 6, 1906, felt unwell since the first week in January. Interval between 
time he was discharged from hospital and time he began to feel ill, about 26 days. 

The sequence of the cases is suggestive of a possible hospital source, but these 
oases have not been included in the hospital list, as we have not sufficient facts on 
which to base a deflnite opinion. 

8. Gunner N., 96th Company, Boyal Gkurison Artillery, had been in St. James' 
Cavalier Barracks, Boom No. 4, for three months. No other case from this room. 
He had been in Valletta Hospital with catarrhal jaundice from February 17 to 
March 6, 1906, during which time he was on milk diet. He began to feel ill about 
March 22, and was readmitted to Valletta Hospital on March 28, and his blood 
reacted on April 6, 1906. There is no evidence of contact. The disease was most 
probably contracted in Valletta Hospital. 



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198 Major McCulloch, Major Weir, and Staff-Surgeon. Clayton. 

9. Prirste B., 46h Rifle Brigade, had been in St. Q^orge's Barracks, Soom No. 6, 
B Block, since aniral in Malta. His medical history is as follows : Mjopia (Forrest 
Hospital), Januaiy 26 to February 5, 1906. Myopia (Valletta Hospital), February 5 
to BCaroh 2, 1906. Beadmitted (Valletta Hospital), for myopia on April 4, 1906, 
and about 18th began to feel ill, and blood reacted on April 23, 1906. He used to 
drink goats* milk when band cook, but he ceased to be employed as a cook on 
January 26, 1906. He had milk in Forrest Hospital from January 26 to February 6, 
1906. The disease was probably contracted at Forrest Hospital. 

10. Lance-Sergeant C, 2nd Essex, was at Q^hain Tuffieha, August, September, 
and October, 1906, then for the next three weeks at Imtarfa, and for the next three 
weeks at Pembroke Gamp, then at Mellieha Camp, and there reported sick with 
gonorrhoea, and was tranferred to Valletta Hospital December 21, 1906, to March 17, 
1906. He was then transferred to Imtarfa to attend hospital. He was discharged 
to duty on March 20, 1906. He was readmitted to Imtarfa on April 6 with fcTer, 
and was transferred to Valletta on April 20, 1906. A week before he left Valletta, 
during his first admission, he had headache, and felt out of sorts. He was on milk 
for a month after his admission, and his disease was most probably contracted in 
Valletta Hospital. He was in contact with Mediterranean Fexer cases in the wards, 
but had no direct relation with the oases. He had nothing to do with the patients. 

11. Q-unner S. — Admitted from a tent in Fort Bicasoli. Medical history : gonor- 
rhoea February 1 to April 7, 1906, Cottonera Hospital; transferred to Imtarfa 
Hospital April 7, 1906, where he remained until he was sent back to VaUetta 
Hospital on April 20, 1906. He had ferer all the time he was in Imtarfa Hospital. 
He stated that he had been in bed with fever at Cottonera Hospital for a few days, 
about March 8, 1906. He had milk at Cottonera from February 2 to 4, &om 
February 7 to 12, and from February 21 to 24. He was feeling out of sorts about a 
fortnight before he left Cottonera Hospital. Only had contact by meeting con- 
ralescent cases in the libraiy at Cottonera ; no known contact outside. 

12. Private E., Royal West Kent, from Boom No. 8, Old Floriana Barracks. 
Medical History : inflammation of ear, Valletta Hospital, March 15 to March 27, 1906; 
gonorrhoea, March 29 to April 9, 1906. He first felt ill on April 14, and was 
admitted April 16, and his blood reacted on April 18. He was in Boom No. 3, 
Old Floriana Barracks, for five days only when he felt ill. He was on milk in 
Cottonera Hospital from March 80 to April 2, 1906. He owned to drinking goats' 
milk at Pembroke Camp on the day before his admission. He denied having ever 
been in a brothel, but had had gonorrhoea. Private P. (Case 5) came from Boom 
No. 3, Floriana (see above). He was admitted March 12, 1906, at which time 
B. was in hospital ; B. almost certainly contracted his disease at Cottonera Hospital, 
and is a possible milk infection, or he contracted his disease at the same time as 
his gonorrhoea. 

18. Q-unner S. — Was admitted from Hut No. 19, Tigne, but up to four days 
before he was in Hut No. 31, and there was no other case from either during the 
year. He had been in Valletta Hospital with psoriasis from April 28 to March 16, 
1906, and was transferred to Citta Vecchia with the same disease from March 17 
to April 2, 1906. From day of his discharge, he did officers' mess fatigues. 
He felt ill on April 13, 1906, and was admitted with Mediterranean Fever on 
April 14, 1906. There is no evidence of contact. He was on ordinary diet and 
one pint of milk at Valletta, and on the same at Citta Vecchia, where his disease 
was certainly contracted. 

14. G-unner K. — Gonorrhoea, from March 4 to March 20, 1906, in Valletta 
Hospital, and was transferred with the same disease to Cottonera Hospital on 
March 21, and he began to feel ill on April 9. Disease was changed to Mediter- 
ranean Fever on April 16. He had milk diet and porridge and milk up to date of 



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Eindemiological Work in 1906. 199 

transfer. He oame originally from Boom No. 18, Upper St. Elmo. There is no 
•eridenoe of contact. Disease was contracted in Valletta Hospital. 

16. Lance-Corporal B., Army Service Corps, in Valletta Hospital, for soft 
ohancre, January 22 to March 16, 1906, then discharged to attend hospital. 
He was not allowed out of barracks (Old Laboratory) except to attend hospital. 
When attending on April 11, 1906, he began to feel out of sorts, and on April 25, 
1906, was found to have a temperature, and was then admitted. His blood reacted 
on April 27. At the time he left hospital, he was on ordinary diet and a pint of 
milk. He had no contact in barracks and no direct contact in 20b Ward, Valletta. 
This is a hospital case. 

16. Gunner B., married man, wife and four children all well, and none of their 
bloods reacted. He came from No. 6, Married Quarters, Vicolo Tigne. The 
medical history is a curious one. Simple continued fever from November 1 
to November 6, 1902. Simple continued fever from October 1 to October 8, 

1905. Simple continued fever from October 14 to November 8, 1905 
(Valletta Hospital). Gout from January 26 to February 5, 1906 (Valletta 
Hospital). Gout from Maroh 17 to April 16, 1906. He developed Mediter- 
ranean Fever at Citta Vecchia on May 4, 1906. His blood reacted May 6, 1906. 
He was not in contact vrith Mediterranean Fever cases either at home or in 
hospital. Condensed milk only is used in his home. He had milk both at 
Valletta and Citta Vecchia. This case probably dates from October 14, 1906, apd 
is most likely a hospital infection, and milk as the agent cannot be excluded. 

17. Gunner M. — ^Arrived in Malta November 10, 1905, and had been stationed 
in Valletta since. Medical history : Cottonera Hospital, gonorrhoea from 
December 2 to December 15, 1905. Valletta, balanitis from January 15 to 
January 19, 1906. (Hstritis and gonorrhoea from February 6 to Maroh 21, 1906, 
in Cottonera Hospital. Gonorrhoea from Maroh 22 to April 10, 1906, and operation 
for varicocele. Was admitted from a tent in Upper St. Elmo Barracks on May 6, 

1906, after feeling ill for a fortnight with headache and soro throat. He had not 
left barracks, except on duty, since last discharge from Cottonera Hospital. He 
was on milk during his last admission to Cottonera Hospital. Thero is no evidence 
of contact. This nuui contracted his disease in Cottonera Hospital, and is a possible 
milk infection. Gonorrhoea was not contracted in Malta. 

18. Private M., 4th Rifle Brigade. — ^Was in St. George's Barracks, but has been 
Almost constantly in hospital since his arrival in Malta. He got a blow on the 
left knee when doing transport work, which resulted in synovitis. From 
December 80, 1905, to January 6, 1906, he was in Forrest Hospital with synovitis. 
He was in Valletta Hospital from February 2 to Maroh 26, 1906, with synovitis, 
and was transferred to Citta Vecchia Sanatorium from Maroh 27 to May 8, 1906, 
and on May 9 Mediterranean Fever was diagnosed. This man probably got his 
disease at Citta Vecchia, whero he was on milk for over a fortnight before he 
began to feel ill. Thero is no evidence of contact either in barracks or hospital. 

19. Gunner B. was quartered in St. James* Cavalier until February, then came to 
Upper St. Elmo. He had the following medical history : gonorrhoea, February 21 
to Maroh 14, 1906, Valletta Hospital ; tonsilitis, Maroh 25 to Maroh 27, 1906, 
Valletta Hospital ; tonsilitis, Maroh 28 to April 2, 1906, Cottonera Hospital. About 
May 8, 1906, his present illness began with headache and pains in limbs, and he 
was readmitted to Cottonera with gonorrhoea. He was transferred to Valletta 
Hospital on May 15, 1906, as a case of Mediterranean Fever. He was in a brothel 
on April 29. He was on milk diet during the time he was in Valletta and Cottonera 
Hospitals for tonsilitis, and again at Cottonera on admission of May 9, 1906. For 
oontact in barracks, see Case 20 below. We think this man contracted his disease 
either in Valletta or Cottonera Hospital. In any case, it is a possible miik 
infection. 



Digitized by VjOOQ IC 



200 Major McCnlloch, Major Weir, and Staflf-Surgeon Clayton. 

20. Chinner B. was in Upper' Sfc. Elmo li yean. Came from Boom 5. Hadl^ 
been in Cottonera Hospital with rheumatio fever, March 23 to April 28, 1906. Hi» 
blood gave negative reaction to Micrococcus meliiensis on March 28, 1906. Buring^ 
that admission he was on milk from March 23 to April 13, 1906. After discharge,, 
he did signalling. He felt ill, and had a swollen right ankle on May 14, and wa« 
readmitted to Cottonera on May 16, and was transferred to Valletta Hospital wit^ 
Mediterranean Fever on May 20, 1906. Blood reacted on May 18. Gunner B. 
(Case 19), who was admitted May 9, 1906, came ^m the same room, but from, 
a bed at the far end of the room, and on the opposite side. It was a large nxmk 
with only six other men in it. Their bloods were examined, but all gave negative 
reactions. We think that the disease was contracted in Cottonera Hospital, and 
is a possible milk infection. 

21. Sapper P. — Simple continued fever from June 19 to June 27, 1905 ; simple 
continued fever from July 7 to July 18, 1905 ; fissure of anus from October 19 to 
November 16, 1905 ; chronic dysentery from January 23 to March 26, 1906, and 
was transferred to the Sanatorium at Citta Vecchia from March 27 to April 9, 1906. 
He was again in Cottonera Hospital, with fissure of anus, from April 16 to May 2^ 
1906. After discharge from Cottonera Hospital, he went to St. Francis Bavelin. 
Barracks, Boom No. 8 (only case from this room during the year), and there did 
light duty, although he was not feeling well, until May 28, 1906, when he felt veiy 
ill. He was admitted for Mediterranean Fever on May 30, 1906. He was on plain 
milk diet for first sevep days of his previous admission to Cottonera Hospital, just- 
a month from the time he felt really ill, and which illness proved to be Mediterranean 
Fever. If this man was not a Mediterranean Fever case from 1905, he most 
probably contracted it at Cottonera Hospital. During his last stay in Cottonera. 
Hospital there were no Mediterranean Fever patients in it. Milk in Cottonera 
Hospital is a possible cause. The bloods of 25 men from his banack room were- 
examined, and that of two men gave a partial reaction (1 in 10). Neither of them 
were or have been ill. Their urines were also examined, with negative results. 

22. Gunner B. was admitted into Valletta Hospital on May 2, 1906, for 
appendicitis. He was in the surgical ward, and had no contact with Mediterranean 
Fever cases. He had his appendix removed on May 22. On May 81 he had 
headache and pains in both legs, and on June 1st, he was sent to the Mediterranean 
Fever wards. Before the admission for appendicitis he had been in Valletta Hospital 
from March 26 to April 24 with a previous attack of the same complaint, and in \h» 
interval between his discharge and readmission he had been in the guard-room at^ 
Tigne Barracks. There is no evidence of contact either in or out of hospital. He 
was on milk during the whole time of his last admission in Valletta Hospital up to 
May 21. 

Valletta Hospital was taken into use for isolating MediterraneaD 
Fev«r cases on May 1, 1906, after which date all Mediterranean Fever 
cases from all parts of the island were sent there for treatment. One 
possible source of infection, i.e., contact with patients in hospital^ 
ended on the above-mentioned date, for Cottonera, Forrest and 
Imtarfa Hospitals. Though this source of danger, t.«., handling bed> 
pans and urinals containing the excreta of Mediterranean Fever 
patients and their soiled linen, ceased for the Royal Army Medical 
Corps orderlies at Cottonera, Forrest, and Imtarfa Hospitals, yet it 
still remained for the orderlies employed at Valletta Hospital. Not> 
withstanding this fact, the orderlies of the Royal Army Medical 



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Epidemiological Work in 1906. 201 

Corps at Valletta enjoyed the same freedom from attack, for the rest 
of the year, as the orderlies in the other hospitals. There were 
two apparent exceptions, but, we believe with reason, only apparent 
and not real exceptions. See Cases 17 and 18 of the Royal Army 
Medical Corps list. We think the immunity from attack of the Royal 
Army Medical Corps orderlies at Valletta Hospital was due to the 
change from goats' milk, as the hospital supply, to condensed milk. 

While fully awake to the probability of other paths of infection 
than milk, we think that occasional lapses from effective sterilisation are 
a reasonable explanation of the occurrence of cases of Mediterranean 
Fever among patients, who were or had recently been in hospital 
suffering from other complaints. 

Another possible explanation for some of these cases is infection by 
flies. When we first visited Valletta Hospital, we noticed numbers ol 
flies on helpless patients, just as they are often observed on enterio 
cases. This possible source of hospital infection was greatly lessened 
at Valletta, about the end of June or the middle of July, by the fact 
that then both the barrack rooms of the men of the Royal Army 
Medical Corps and the Mediterranean Fever wards were protected 
from flies by using wire net doors and by fixing mosquito net frames 
in all the windows. This measure, though perhaps not required for 
the purpose for which it was originally designed, was most efficient in 
the exclusion of flies, both from the barrack rooms and wards. 

An examination of the diet sheets of patients in Valletta Hospital 
during the year 1905 seems to aflbrd confirmatory evidence that milk 
in hospitals has been a causative factor of Mediterranean Fever. 

Examination of the Diet Sheets of Patients in Valletta Hospital during 
1905. — The diet sheets of patients in Valletta Hospital, during 1905» 
were examined to see whether there was greater prevalence of 
Mediterranean Fever among men who had taken milk diet, or extra 
milk, while in hospital for disease other than Mediterranean Fever, 
when compared with men who had been in hospital under similar 
conditions, but without having had milk diet or extra milk. Two 
thousand and thirty-one diet sheets were examined, of which 190 were 
found to be useless for the purpose of the enquiry and therefore were 
rejected. The 190 sheets were those of men who fall under three 
heads : I. Patients who were admitted into Valletta Hospital for 
Mediterranean Fever, without having had any previous admission for 
any other disease during the year ; II. Patients who were transferred 
to Valletta Hospital from other hospitals, and whose previous history 
is unknown ; III. Patients (a few) who had no record of their disease 
on the diet sheet. After subtracting these 190 from the original total» 
there remain 1841 diet sheets for examination. Of these, 1460 belong 
to men who had been in hospital one or more times during the year ; 
all had received either milk diet or extra milk, or both, while the 



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202 Major McCulloch, Major Weir, and Staflf-Surgeon Clayton. 

remaining 381 are those of men who had also been in hospital one or 
more times during the year, but who had received no milk in hospital, 
except in tea. Of the 1841 diet sheets, 176 are those of men who 
were readmitted for Mediterranean Fever, and all of whom had 
previous admissions during the year for other diseases. Of these 
176 men, 172 had had milk in hospital before their admission for 
Mediterranean Fever ; the remaining four men had no milk while in 
hospital, except in tea. From these figures it appears that 1460 
patients who had taken milk when in hospital suffering from diseases 
other than Mediterranean Fever subsequently gave 172 cases of that 
•disease, while 381 patients who had no milk in hospital subsequently 
gave four cases. The ratiojjfor the larger group is 11*8 per cent., for 
the smaller group 1*05 per cent. The 172 patients who were in 
hospital for one or more diseases within the year and were admitted 
later for Mediterranean Fever have been classed under three headings. 
Of the following three tables, No. XI shows the quantity of milk, in 
pints, which each patient had in hospital, before his readmission for 
Mediterranean Fever. No. XII the time, in weeks, each patient had 
milk in hospital, before his readmission for Mediterranean Fever, and 
No. XIII the interval, in weeks, between the last day on which a patient 
had milk in hospital and the date of his readmission for Mediteranean 
Fever. 

Table XI. 





A. 


B. 


c. 


D. 


E. 


F. 




r 




d 


^ 


^ 


8 




1 




r^ 


»4 


u 


u 










S 




^ 


■s 






Quantity of milk 
in pintff "^ 


5 


g 


§ 


§ 


? 




lO 




a' 


5' 


o 






^1 




»4 

4) 


i 


»4 


s 


"s 




P 


6 


6 


O 


o 


8 


^ 


Kumberof patients... 


10 


16 


81 


60 


28 


42 


172 


Poroentage of patients 


6-8 


9-8 


18 


29-1 


13-4 


24*4 


100 


in each class | 















Digitized by VjOOQIC 



Epidemiological Work in 1906. 



203 



Table XII. — Length of Time in Weeks during which Patients who later 
were readmitted for Mediterranean Fever had Milk in Hospital. 



Time 



B. 

-J 



: '(S^ 



c. 


D. 


E. 


F. 


o. 


u 


»< 


>4 


^ 


. 


a> 


« 


« 




S 


TS 




'a 


^o 


•^ 


M 




§^ 


3 pM 


^ 


»-£ 


«rSJ 


^-^ 


^j-S 


CO 


t. » 


». ^ 


*- ^ 


!< * 


»« 


!;« 


Sl^ 


► »o 


I'' 


2 


o 


o 


^ 


o 



Number of patients ... 63 
Percentage of patient* 86 '6 



34 



19 -8 16 -8 



20 



10 



11 -6 5 -8 



2*3 



18 



^ 



172 



7-6 100 



Table XIII. — Interval in Weeks between Date on which Patient had Last Milk and 
Date of readmission for Mediterranean Fever. 



Time- 



Number of 
patients 

Percentage of 
patients 



17» 
9-9 



B. 



9 
6-2 



C. 



9 
6-2 



D. E. 



t I & 

a Q 



15 

8*7 



15 

8-7 



F. 


O. 


H. 


i 


M 


• 


I 


I 


SI 


► 


^ 


^ 


CO 


l^ 


00 


u 


h 


»« 


9> 


O 


o 


TS 


TS 


»« 


a 


a 


a 


t) 


P 


t) 


25 


18 


12 


14-6 


7-6 


6-9 



I. K. 



J 
^ 
^ 



8 
4-7 



3 9 
1 7 I 5 -2 



1 






— - 


M.| N. 






.* J 






^ 


n 






t 


S^ 


•f? 


1 


^ 


«« 


g 






$ 


S 






5 
^ 




•a 


P 


t3 


o 




4 


8 


25 


172 


2 8 


4-7 


14-6 


100 



* The following six cases, which were those of patients who were taking milk when the 
diagnosis of Mediterranean Ferer was made, have been included in Table XIII — A : — 

1. Case No. 88. — Gimner S., 4th Bojal Garrison Artillery, was admitted 
Januarj 9, 1905, with gonorrhoea, and when in hospital with that disease he was 
diagnosed as a case of Mediterranean Fever on March 8, 1906. He had milk in 
January, and all through February. 

2. Case No. 43.— Priyate Y., admitted August 22, 1905, with enteric ferer, during 
the course of which he was diagnosed, October 8, 1906, as a case in which 
Mediterranean Fever had supervened. He had milk all through his illness. 

3. Cose No. 107.— Private G., admitted May 14, 1905, for gonorrhcea. On 
July 1, 1906, he was diagnosed as Mediterranean Fever. He had had milk during 
the whole period in hospital. 

4. Case No. 113. — Private O., Ist Eifle Brigade, admitted for gonorrhoea on 
May 2, 1905, and was diagnosed as Mediterranean Fever on June 16, 1905. He 
had 21 pints of milk in May, and was on milk all through June. 

6. Case No. 119.— Private W., admitted May 30, 1905, for enteric fever, and was 
diagnosed July 16, 1905, as Mediterranean Fever. He had been on milk from 
first date. 

6. Case No. 161. — Acting Bombardier L., Royal Garrison ArtiUery, admitted 
September 11, 1905, for liver abscess, and was diagnosed Mediterranean Fever 
November 10, 1905. He had milk from first date. 



Digitized by VjOOQ IC 



204 Major McCulloch, Major Weir, and Staflf-Surgeon Clayton. 

The 381 men who had been in hospital, but had no milk, are 
divided into two groups, men who were not readmitted for Mediter- 
ranean Fever, and men who were. In the first group there were 37T 
men ; in the latter group there were four. 

Table XIV shows the time, in weeks, spent in hospital by all the men 
who were not readmitted for Mediterranean Fever. 











Table XIV. 














Time in 


1 . 

5 






1 


t 


i 


t 


over, 
over, 
over. 


i 


o 




weeks../ 


1 


1 


1 


1 


1 


1 


1 


1 


1 


1 


1 


and 
tal. 


^ 




09 


CO 


'^ 


to 


CD 


t* 


00 


o 


s 


iH 


s i ^ 


Number of , 146 


101 


44 


I 1 1 1 1 

35 ' 18 8 6,82 


1 


1 


13 


377 


men 






1 I * 










Percentage ; 89 '4 


26-5 


11-5 


9-2 3-4 21 l-8j21 


0-6 


0-3 


0-3 


8-4 


100 


1 of men j 






1 1 1 

1 , 1 1 















The four men who had been in hospital during the year, but who 
had no milk, and were admitted during the same year with Mediter- 
ranean Fever, had the following history : — 

1. PriTate S. was admitted December 27, 1904, to February 6, 1906, with sjnovitiB^ 
of right knee. Had no milk in hospital. He was readmitted on NoTember 8^ 
1906, with Mediterranean Fever. Intenral, in weeks, between discharge from 
hospital and readmission, 39. 

2. Private W. was admitted from December 21, 1904, to January 6, 1906, witk 
rheumatism. He had no milk in hospital. He was readmitted for Mediterranean 
Fever on May 21, 1906. Interval, in weeks, between discharge and readmission, 19.. 

3. Gunner R. W. was admitted from February 10 to March 22, 1906, for soft 
chancre. He had no milk in hospital. He was readmitted November 1, 1906^ 
with Mediterranean Fever. Interval, in weeks, between discharge and re- 
admission, 82. 

4. Private W., Royal Army Medical Corps, was admitted from June 4 to June 7^ 
1906, with contusion. He had no milk in hospital He was readmitted August 7^ 
1906, with Mediterranean Fever. Interval, in weeks, between discharge and 
readmission, 8. (Hiis man was sergeants' mess waiter.) 

From the above history it appears extremely unlikely that hospital 
influence had any causal relation to the subsequent admission of any 
of these four men. 

We think that the deductions which may be drawn from thia 
examination are : — 

1. There is evidence that the probability of a patient being^ 
subsequently admitted to hospital for Mediterranean Fever bears a 
direct relation to the quantity of milk he has had in hospital, and 



Digitized by VjOOQ IC 



Epidemiological Work in 1906. 205 

increases with an increase of the milk he had had when in hospital 
(see Table XI). 

2. That there is little relation between the actual length of time 
any patient was on milk in hospital and the probability of his 
subsequent readmission for Mediterranean Fever. The relation is 
rather one of quantity of milk than of time. 

3. That over 80 per cent, of men who were readmitted with 
Mediterranean Fever were readmitted within 90 days from the date 
on which they last had milk in hospital, while over 50 per cent, of 
these subsequent readmissions took place within six weeks from the 
date on which the patient last had milk. 

4. That men who have been on milk in hospitals for longer or 
shorter periods show over 10 times the incidence as compared with 
men who have not had milk during their previous stay in hospital 
when suffering from other complaints. It is to be noted further that 
milk is used in hospitals in much greater quantities during the hot 
weather months than during the cold, that is to say, a larger quantity 
of a presumably infected article is then used. 

Series 4. — Other Cases of Possible Milk Infections, 

1. Gunner S., No. 1 Company, Bojal Qarrison Artillery. — Admitted December 31, 

1905, to January 18, 1006, from Fort Benjemma, where he had been for eight months. 
He stated that, before he got ill, he frequently drank egg flip, and sometimes had 
groats' milk and soda water. There was no history of contact in this case. 

2. Private E., Ist Bifle Brigade. Admitted December 81, 1906, to Januazy 21, 

1906, from St. Andrew's Barracks, J block. There was no other case from the loom 
during the year. He stated that he drank goats' milk freely, as he said he thought 
it did liini good. He was admitted for rheumatism, and his disease was changed on 
January 5, 1906. 

3. Private L., Ist Lancashire Fusiliers. — This man came from Boom No. 8, Lower 
St. Elmo. He was admitted on January 1, 1906, from Mellieha Gamp. He had 
two previous admissions for simple continued fever in 1905, namely, from June 12 
to June 17, 1905 ; and again from November 22 to November 27, 1905. He had 
milk in Cottonera Hospital during his last admission, otherwise only milk in his tea. 
There is no evidence of contact. 

4. Private S., 1st Lancashire Fusiliers. — This case was a probable relapse from 
1906. He had been in Gitta Yecohia with simple continued fever from July 14 
to September 4, 1905. He was readmitted January 4, 1906, with Mediterranean 
Fever, from Pembroke Camp. He was not personally examined, but a man of his 
company told one of us that he drank egg flips and rum and milk frequently. 
This man was a companion of his, and said he had often warned him of the danger 
of drinking milk, " as the doctor had warned them against milk drinking." 

6. Gunner G-., 96th Company, Boyal Garrison Artillery. — Admitted January 5, 
1906, from the officers' mess, where he had been an officer's servant for three months. 
He slept in a room by himself (No. 7, Servants' Quarters, Castile Mess). There is 
no history of contact. He had access to milk in the mess. 

6. Lance-Corporal T., 1st Lancashire FusiUers, a relapse from October 30, 1905, 
to January 15, 1906. He was readmitted February 17, 1906. This man stated 
that before his first illness he used to drink unboiled goats' milk, but had not done 
«o recently. 



Digitized by VjOOQ IC 



206 Major McCulloch, Major Weir, and Staff-Siirgeon Clayton. 

7. Gunner L., 102nd Companj, Boyal Ghiirison Artillery, was admitted 
February 20, 1906, from Tigne Old Fort. Was a company oook for three months 
before he got ill. Q-oats' milk was used in the cook-house by the cooks, who used 
to buy it for their own use. This man stated that he had drunk goats' milk and 
soda water within 80 days of his getting ill. 

8. Private W., 1st lAUoashire Fusiliers, had been in Valletta Hospital ezactlj 
one month before his Mediterranean Fever admission on March 2, 1906, with 
rhinitis. He said he only drank milk in his tea, but he put the milk into the tea 
liimself, i.e.f it was not served with the milk in it. 

9. Private T., 1st Lancashire Fusiliers, was employed in the cook-house at Lower 
St. Elmo for 12 days before he fell ill. He used to drink unboiled goats* milk daily 
while there. He attributes his illness to this. 

10. Private F., Ist Lancashire Fusiliers, was a relapse from 1905. That attack 
was probably contracted in hospital, as, within a month of his readmission for 
Mediterranean Fever, he had been in hospital with gonorrhoea, and said that he 
never felt well after his discharge from hospital after the cure of the gonorrhoea. 
He had milk in hospital and in his tea. 

11. Sergeant M., 2nd Essex Regiment. — Admitted March 21, 1906, at Imtarfa. 
This case is a possible rekpse from August 2, 1906, when he was in with simple 
continued fever until August 18, 1905, and then had a fortnight's light duty, and 
since then has suffered from pains in different limbs. He drank goats' milk on 
several occasions, but cannot give approximate dates. He had had goats' milk 
in tea in sergeants' mess. 

12. Schoolmaster M. was admitted on March 23, 1906, but probably contracted 
his disease in January last. His wife also had the disease, and probably contracted 
it at the same time as her husband. They both drank unboiled goats' milk from 
the herd which supplied the Royal West Kent Regiment. Their son had 
Mediterranean Fever a year ago, when they were living at Sliema. Mrs. M. then 
nursed her son, and did not contract the disease. At present they are living in 
No. 2, Warrant Officers' Quarters, Strada Cappucini, and the son has never lived in 
the quarters. Several other cases of Mediterranean Fever occurred in this house^ 
and a factor common to all these families was the milk supply. 

13. Gjlour-sergeant S., 4th Worcester Regiment, was admitted into hospital 
on April 14 from No. 18, Verdala New Married Quarters. This man's child was 
admitted with Mediterranean Fever on March 2. He had been in camp for some 
time before his child got ill, but had slept in his house at least twice, February 3 
and February 10. He was in Valletta Hospital March 19 to Marvh 28, 1906, for 
sprain (knee). He and his wife both stated that condensed milk only was used 
in the house. We have reason to distrust this statement, as we were informed by 
a responsible officer of the regiment, who knew the family well, that they were 
well known in the regiment as goats' milk drinkers. 

14. Private P., 2nd Essex, was admitted from No. 83 hut, Tigne (military 
police hut, a hut that has constantly changing inhabitants from different corps 
in the island), on May 7, after feeling ill for three days. Two other cases occurred 
of men who had been residents in this hut during the year : 1st, Private O., of the 
4ih Rifle Brigade, who was admitted on May 21 after leaving this hut only throe 
days. The second case was a man of the West Kent Regiment, Private H. (see 
Case No. 81, West Kent Regiment), who was admitted into hospital on June 6. 
This man, however, had left the hut at Tigne over seven weeks when he got ilL 
None of these men's beds were near each other, and none of the three men were 
acquainted with each other. Private G., of the 4th Rifle Brigade, we believe, 
contracted his disease by drinking milk at his sister's house. This man's (G-.'s) 
sister was married to a sergeant of the Ist Rifle Brigade, and he used to visit there 



Digitized by VjOOQ IC 



Epidemiological Work in 1906. 207* 

almost daily. The bloods of all the occupants of this hut were examined, ¥rith 
negative results. Private P., we considered, might have possibly contracted 
Mediterranean Fever by eating Goso cheese, but we could form no opinion as to- 
where the West Kent case contracted his disease. We did not consider the super- 
vision at Tigne was all that could be desired, e.g.^ we found that when condensed 
milk was alone supposed to be in use among the men at Tigne, goats* milk was 
still in use by the cooks in Tigne cookhouse. We, on one occasion, found goats' milk 
in the cookhouse. It was imboiled. We cannot exclude contact in the three casea^ 
from this hut, but at the time we did not think that contact was at all a soimd 
explanation of them. 

16. Private F., Ist Rifle Brigade, had no previous illness in Malta, was admitted 
on May 18, 1906, after feeling ill for five days. He lived in the Servants' Quarters,, 
officers' mess, St. Andrew's Barracks, where he had a room to himself. He used 
to drink the milk which was left over from hb master's morning tea daily. There 
is no history of contact. This milk supply was known later to come from a herd 
which contained infected goats. 

16. Private G., 4th Bifle Brigade, was admitted on May 21, 1906, from 
St. 6korge*s Barracks, to which he had only returned from Hut No. 83, Tigne> 
a few days before. This vnis the most severe case of all the attacks during 1906 
which ended in recovery. The probability of contact has already been discussed in. 
this case (see Case 14). We think P. contracted his disease from milk at his 
sister's house in St. Andrew's Barracks. 

17. Gunner L., 102nd Company Royal Gurrison Artillery, was admitted from 
Room 4, A Block, Tigne, on May 14, 1906. The case is discussed along with Case 18. 

18. Gunner H., 102nd Royal Gkurrison Artillery, was admitted May 25, 1906, 
from the same room as Gtmner L. These men were intimate friends. They were 
in the habit of knocking about together, and both frequented the " Welcome to All ** 
house at Sliema, where they often had tea together. They only had condensed milk 
in barracks. Gunner L., though admitted first, probably was iD before Gunner H. 
All the bloods of the other occupants of Boom 4, A Block, were examined, and with 
negative results. We think that these men contracted their disease at the same 
time and place, which probably was not Room 4, and, though contact is a possible 
explanation, yet we do not think that mUk infection can be excluded. 

19. Gimner L., 99th Company Royal Garrison Artillery, was admitted from Tigne, 
Hut No. 82, on June 22. This man has complained of severe headaches on and off 
since April, when he had some teeth extracted. He was employed in Tigne cook- 
house, and states he used unboiled goats' milk in his tea. It was in this cook-house 
we found the cooks using goats* milk, when the only barrack supply was supposed to- 
be condensed milk. This man had been a cook for 13 months. There is no evidence 
of contact. 

20. Sergeant-Major A., King's Own Malta Militia, was admitted on June 30 from 
14th Strada Cappucini Warrant Officers' Quarters (iee Schoolmaster M.'s case. 
No. 12, Series 4). His wife was admitted with the same disease May 12, 1906. 
There were two children in the quarters. The husband and wife used unboiled 
goats' milk, the children used condensed milk. Neither of the children got ill. It 
is improbable that the husband contracted the disease from his wife, as she was in 
hospital since May 12. During Mrs. A.'s stay in hospital she had a confinement, 
and a few days later Microeoccu» melitentis was recovered from her milk. Beginning 
as a mild, she became a very severe attack. Shortly after her husband's admission 
his blood reacted 1/500,000. The baby which was bom began to run a temperature 
at once, and its curve was exactly parallel with the mother's curve. The baby was 
bottle-fed, and infection was probably intra-uterine. We consider both Sergeant- 
Major A. and Mrs. A. to be cases of milk infection. 



Digitized by VjOOQ IC 



208 Major McCulloch, Major Weir, and Stafif-Surgeon Clayton. 

21. Sergeant E., 2nd Essex, was admitted June 2, 1906, after feeling ill for three 
days. He came from the Married Quarters, Imtarfa, 1.0 Block. The familj 
consists of Mrs. K. and four children. All the family are goats' milk drinkers. 
Mrs. K. had ferer in June last. Sergeant K. had Malta Ferer July 8 to July 16, 
1904. His present attack is a relapse or a re-infection. This man states that he 
lirank unboiled goats' milk, but not since April 22, 1906. The children in this 
family are said to hare only boiled goats' milk. We consider that this was 
A milk infection. 

22. Bombardier A., 65th Company Royal Ghirrison Artillery, was admitted from 
No. 41 Room, Upper St. Elmo, on July 8, 1906, after feeling ill since the end of 
May. This man, who was a pupil-teacher in the children's school, yeiy frequently 
drank imboiled goats' milk in different shops in Valletta. There is no evidence of 
-contact. He drank milk up to the time he got ill. 

28. Private Q-., 2nd Essex, was admitted on September 8 from Marsumacetto 
Barracks, where he was attached to the Chirrison Military Police. This man was 
<K>ok to the police and used to buy a pint of goats' milk daily from any passing goat- 
herd. He used to drink it imboiled. The milk supply of these barracks is 
•condensed milk. 

24. Quartermaster-Sergeant 0., Army Ordnance Oorps, was admitted on Sep- 
tember 7 from No. 7 Strada Birchiroara, Sliema. He was a relapse from 1905. 
Mrs. C. also had Mediterranean Fever this year, and may have been infected through 
her husband, who this year was foimd to be excreting Micrococcut melitentu in his 
•urine. When Quartermaster-Sergeant C. vras iU last year, his son also had the 
•disease at the same time and was nursed by Mrs. C;, who then did not contract the 
•disease. All the members of this family drank goats' miUc, sometimes boiled and 
-sometimes unboiled. Mrs. C. was imder the impression that it was cows' milk they 
got, but found out later that her milkman only kept goats. Whether Mrs. C. got 
i;he disease from her husband or not, there is ample evidence that both father, 
mother, and son were running daily risk of infection through miUc. 

25. Private F., 4th Worcesters, was admitted August 13, 1906, from Fort 
«Chambray, 6K>zo. This man, until 14 days before his admission, was employed in 
Fort Ghambray cook-house, where the milk used was said to be cows' milk. It was 
this man's duty to sterilise it, and he said he used to use it in his tea. There was no 
iiistory of contact. 

26. Gunner H., 68rd Company, Royal Garrison Artillery, was admitted from 
Ricasoli on September 8, after having felt ill^ since July 11, 1906. On June 17, 

^after a cricket match, he' drank a quantity of unboiled goat's milk. 

27. Gunner W., 65th Company, Royal Garrison Artillery. — After having felt iU 
since July 7, 1906, was admitted into hospital on September 7. This man had 
drunk goats' milk freely at Pembroke Camp in June last, and said it was commonly 
done in camp. He also drank egg flips, which contained goats' milk. This man 
was in Room 39, Upper St. Elmo, for the past 12 months, and no other case has 
occurred in the room this year. There is no history of contact. We believe this 
man, though only admitted in September, contracted his disease at Pembroke Camp 
in June, where he was from June 1 to Jime 14, as he began to feel ill within ihiee 
weeks of leaving camp. 

Series 5. Men who wei'e Probably Infected through Animals other than Ooals. 

Gunner L., 65th Company, Royal Churison Artillery, was admitted to hospital on 
July 80, 1906, and his blood reacted on the same day. He had felt ill for two days 
before his admission with headache and general malabe. He is the second case 
4idmitted from St. James Cavalier during the year. The first was Gunner N. (see 



Digitized by VjOOQ IC 



Epidemiological' Work in 1906. 209 

<3afle 8, Hospital List), who oame fiom another room. Gunner L. oame fiom 
Boom 6, and had been in this room for three years. His employment was that 
•of groom to Captain S.'s ponies. The stables where he worked were in St. James's 
Ditoh, the surroundings of which were not in a very sanitary condition. The man's 
diet throws no light on the cause of his disease. One of the ponies with which he 
-worked, pony " Billy," gave a good reaction against Micrococcus melitenrU. This 
^aot was not discovered until September, when another groom, Gunner W., was 
-admitted (September 3, 1906) from the same room as Gunner L. had come from. 
W.'s bloody like that of the first groom, gave a positive reaction on the day of his 
admission. Gunner L. and Gunner W. had worked in the same stable, and both 
•" had to do ** with pony " Billy " and pony " Benghiza," the bloods of which ponies 
reacted well to Micrococcus melitensis. The bloods of eight men from Room 6 
*were examined at the same time, and none of them gave a positive reaction. Neither 
^Gtinner L. nor Gunner W. had ever taken goats* milk, and it seems liighly probable 
that these men were infected through handling infected ponies. As to the way the 
ponies may have been infected it seems not improbable that their food may have 
been infected by urine of goats which a short time before used to be kept in large 
numbers in St. James's Ditch. None of the other occupants of the rooms got the 
disease, and none of them were grooms. It is much moro probable that the 
^nies were the souroe of contagion than anything in the barrack room. 

Gunner H., 99th Company, Boyal (Harrison Artillery, was another case in which 
^e could find no other likely souroe than through infection from a pony. He lived 
in 21, Strada Jacinta Sliema, was groom to Captain A.'s ponies, and worked with a 
pony whose blood reacted well (1 in 10, and 1 in 20). Gunner H. was a married 
man, and had lived in his present house for the past six months. The house was 
in good sanitary condition, and no case of illness had occurred in it. His wife was 
in good health, and her blood gave a negative reaction. Gunner H. first fell ill on 
August 14, 1906, and was admitted to hospital on August 21. His blood reacted 
•on August 20. The case from the first was one of great severity. Goats' milk was 
never used in his house. There was no evidence of contact except with the pony. 
The blood of the pony was examined for Micrococcus melitensis, but the attempt 
to recover it was unsuccessful. This is not a frequent path of infection, as the risk 
-is confined to a very limited class of persons. 

The remaining 33 cases have not been detailed, as we were unable 
to come to any definite opinion as to their causation, and they throw 
010 light on the question of contact or other path of infection. 

6. Occupation in Relation to Attack, 

The liability to attack of the men of the Royal Army Medical 
CJorps has already been discussed and need not be further referred 
to. In barracks, cooks, oflRcers' servants and mess waiters have 
sofifered severely. 

Sixteen men employed in barrack cook-houses contracted the disease 
during the year, 12 of them being cases that occurred prior to the 
milk change. In nearly every instance there is a history of taking 
goats' milk. 

Twelve men who were employed as officers' servants contracted 
Mediterranean Fever during the year, and in every case they were 
employed during the time when goats' milk was being used in the 
(2089) p 

Digitized by VjOOQIC 



210 Major McCulloch, Major Weir, and Staff-Surgeon Clayton. 

officers' mess; or in instances where it had been stopped, the men 
fell ill within 30 days of the time when the mess ceased to use 
goats' milk 

Six men who were employed as mess waiters contracted the disease 
during the year, and all at the time the messes were using goats' milk. 
After the milk change this class of case ceased. 

There does not appear to be any special liability to attack on 
the part of men who had been employed on sanitary work, such as- 
work connected with drains, urinals, moving urine tubs, latrine 
work, etc. 

The three cases of grooms which have just been detailed, and the 
three laboratory attendants who contracted the disease— one in 1905- 
and two in 1906 — are of interest as pointing to contact as the path of 
infection. • 

7. Prevalence amongst Officers, 

During 1906, 10 officers contracted Mediterranean Fever. One 
was an officer of the Eoyal Garrison Artillery about whom we obtained 
no information, except that goats' milk was used at the mess where 
he lived, and that it was used unboiled. Four were officers of the 
Boyal West Kent Regiment. Lieutenant F. was admitted to hospital 
on March 18 after feeling ill for a fortnight. Lieutenant L. W. was 
admitted on April 16 after feeling ill for two days. Lieutenant W. 
was admitted on May 8 after feeling ill for four days. Captain S. 
was admitted on June 3, but had been feeling ill since the end of 
April. None of these officers had any real contact with each other 
beyond living in the same building and having meals together. Ne 
two cases occurred from one room. All these officers stated that they 
had only used boiled milk so far as they knew. Orders had been 
given that all goats' milk was to be boiled, and the Mess President 
was quite confidiant that these orders had been strictly enforced. 
By means of the ortol test it was proved on several occasions that 
the milk had not been boiled. All the West Kent officers got ill 
before they had ceased using goats' milk in the mess. Condensed 
milk was taken into use on May 25. Captain S., though admitted in 
June, was ill from the end of April. 

Two officers of the 1st Rifle Brigade got ill about the same time. 
Lieutenant Hon. W. was admitted on April 21 after feeling ill for 
about a week. Captain D. was admitted on April 25 after feeling 
ill for 10 days. We could find no connecting link between these 
two officers, except that one of them began to take porridge and milk 
three weeks before he got ill, while the other officer had begun 
taking porridge and milk a month before he got ill. One of the 
officers said he knew the milk was boiled, because on the first 
occasion he used it it was hot, but that he always got the milk cold 



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Epidemiological Work in 1906. 211 

afterwards, as he had scolded his servant for bringing him hot milk. 
It appears probable, ia consequence of this scolding, that the officers 
in future had unboiled milk. There was no evidence of contact in 
either of these cases. 

Captain P., Hampshire Kegiment, was admitted to hospital on June 10, after 
feeling ill for a week. He was living in private lodgings and used to have all 
his meals, except his breakfast, at the Union Club. This officer's servant got ill 
about three weeks before his master. He used to use unboiled goats' milk for his 
tea. His servant used to have tea at his master's quarters. We think that master 
and servant were most probably infected hj milk. 

Lieutenant B., 4th Worcester Regiment, was admitted into hospital on July 1 from 
the Officers' Quarters, Yerdala Buracks. This officer was on the sick list for five 
days about Christmas, 1905, with simple continued fever, and again in Egypt he had 
another attack of fever which lasted for a few days. This was about May 20. 
Since then he has never felt fit and had headache frequently. This officer used to 
take porridge and goats' milk before he went to Egypt, not since he returned to 
Malta. It is extremely probable that the disease was contracted before he went to 
Egypt. There is no evidence of contact. No other officer of this regiment has had 
the disease this year. 

Lieut.-Colonel Y., Army Pay Department, was placed on the sick list on 
October 11, 1906. We know nothing about this officer's illness, which took place 
after we left Malta. 

The deductions to be drawn from the incidence of the disease 
among officers are : — 1. In the cases of the officers about whom we 
obtained personal information, all except two, there was a history of 
drinking goats' milk. 2. Since goats' milk has been discontinued, no 
other officer has been attacked by Mediterranean Fever. 

8. Prevalence in Married Quarters. 

A family forms a small group of individuals living in close 
association, and in each set of married quarters there are many such 
small groups, each living amidst the same general surroundings, but 
differing from each other often in one important respect, namely, in 
regard to the kind of milk used. 

This year's examination of the kind of milk used by the families 
showed the following results. 

Four hundred and sixty-five families were examined. These 
families comprised 1830 persons, 465 men, 465 women, and 900 
children. Among them there occurred, during the year, 59 cases of 
Mediterranean Fever, 3*2 per cent. The men gave 21 cases, and the 
women and children each gave 19 cases, the respective ratios being, 
men 4*5 per cent., women 4*1 per cent., children 2*1 per cent. ; 
266 families, composed of 266 men, 266 women, and 436 children, 
with a total of 968 persons, whose only supply was condensed milk, 
gave 10 cases of Mediterranean Fever, 103 per cent.; while 
(2089) p 2 

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212 Major McCuUoch, Major Weir, and Staflf-Surgeon Clayton. 

199 families, consisting of 199 men, 199 women, and 464 children, 
total s 862 persons, whose milk supply was either goats' milk alone or 
goats' milk and condensed milk, gave 46 cases of Mediterranean Fever, 
being a ratio of 5*3 per cent. 

Percent. 

Of the 21 men, 15 had goats' milk 71-5 

„ 4 had condensed milk 19*0 

„ 2 milk supply unknown 9*5 

These four men include one (Sergeant S.) whose milk history is 
unknown and he is assumed to have used condensed milk only. 

Percent. 

Of the 19 women, 9 had unboiled goats' milk 47*4 

„ 8 had boiled goats' milk 42*1 

„ 2 had condensed milk only 10*5 

Of the 19 children, 8 had boiled goats' milk 42*1 

„ 5 had unboiled goats' milk 26*3 

„ 4 had condensed milk 21*1 

The histories of two are unknown 10*5 

It is seen that, for this year, families whose only supply was 
condensed milk give a Mediterranean Fever rate of 1*03 per cent., 
while families which used goats' milk, either entirely or in part, give 
a rate of 5*3 per cent, Le,, there are more than five times as many 
cases in the group using the dangerous article than among those using 
the safe one. The figures obtained with regard to those who used 
boiled goats' milk as compared with those who used unboiled goats' 
milk do not show the same amount of protection as is shown by the 
condensed milk group compared with the goats' milk group. This is 
only what one might expect. In our inquiry some women said they 
boiled the milk always, others said the milk was sometimes boiled, not 
always, others again said it was " scalded," and again that it was only 
used unboiled for tea. The only safe comparison to make, or one 
which with any degree of probability represents the truth, is the 
comparison of families which used condensed milk against families 
which used goats' milk, boiled or unboiled, and, using this comparison, 
the figures are all in favour of the condensed milk users. 

The following table gives the monthly distribution of the disease 
among the married men, women and children during the year. 



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Epidemiological Wo7*Jc in 1906. 



213 



1906.. 





1 


£ 


1 


t 


1 


1 


i 


A 


i 


1 


1 


1 


1 


Men 


1 





1 


8 


8 


(\ 


1 


2 


1 


1 


7 


1 


21 


Women 





1 





1 
8 7 


1 


2 


1 


2 





1 


1 


19 


Children 





1 


2 


6 


1 


6 


8 





1 


1 


— 


19 



During the first six months of the year the men had 14 cases of 
Mediterranean Fever and during the second half of the year seven 
cases. 

The women, during the first six months, gave 12 cases, during the 
second six months seven cases of Mediterranean Fever. 

The children, during the first six months, gave nine cases, and 
during the second six months ten cases of Mediterranean Fever. 

There are no data against which these figures can be compared, as no 
monthly distribution of the disease among families has been given in 
previous records. 

9. Mosquitoes and other Bitvng Insects. 

In none of the cases examined this year could we obtain any 
evidence of the spread of Mediterranean Fever through the agency of 
mosquitoes or other biting insects. The majority of the patients 
stated that they had not been bitten, and at the time we examined 
them they had no visible marks. Such evidence is, of course, very 
lyeak for determining a question of this nature. Evidence on which 
we place more importance is, that we examined a large number of men 
in barracks, and of children in quarters, who had been severely bitten 
by both mosquitoes and sand flies, some sufficiently badly bitten as to 
cause their admission to hospital through injury to the skin caused by 
scratching. None of these severely bitten individuals were sub- 
sequently admitted with Mediterranean Fever. It is hard to believe, 
supposing the mosquito to play any large part in the spread of this 
fever, that this should have been the case. The disease was also most 
prevalent in the first six months of 1906, when mosquitoes were few, 
and the prevalence was far less in July, August, and September, when 
they were abundant. 

From May to the end of September we examined 222 mosquitoes 
sent to us from different barracks in Malta, with the following results : 
From Floriana Barracks 97 specimens were examined, of which 52 



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214 Major McCulloch, Major Weir, and Staff-Surgeon Ckyton- 

were Culexpipiens or faiigans, 29 were Stegmiyia fasdaia^ and 16 were 
Cvlez spathipdlpis. From St. George's Barracks — 39 mosquitoes, of 
which 23 were Culex pipiens, 10 were Acartomyia ZammUiiy and 6 were* 
Stegomyia fasciata. From St. Andrew's Barracks we received 42 
mosquitoes, of which 27 were Culexpipiens, 11 were Stegomyia /(tscialaj 
and 4 were Acartomyia Zammiiii, From Tigne Barracks and married 
quarters 44 mosquitoes were received, of which 16 were CuUxpipiensy 
18 were Stegomyia fasciata, and 10 were Acartomyia Zammiiii. 

As the Stegomyia fasciata did not appear until June, and the 
Acartomyia Zammiiii ceases in September, neither of these species 
can have much to say to the occurrence of cases during the cold 
weather months. 

On the initiative of the Principal Medical (Mcer, Colonel 
MacNeece, a joint Committee, consisting of representatives of the 
Civil Government, and the naval and military authorities, was 
appointed to discuss the question of ways and means of lessening 
mosquito prevalence in Malta. The Committee had not reported up to 
the time we left the Command. 

10. Preventive Measures. 

The measures in use when we arrived in Malta were as follows : — 

The sanitary conditions of barracks and quarters were under 
constant supervision, and there was much sanitary activity on the 
part of both medical and regimental authorities. Courses of lectures 
are regularly given by the Command sanitary officer, Major 
W. L. Gray, R.A.M.C., on subjects relating to barrack sanitation and 
the laws of health. 

In barracks and married quarters, the sterilisation of goats' milk by 
boiling had been strictly enjoined, and the hospital supplies were dealt 
with by pasteurisation in the case of Valletta and Cottonera, and by 
boiling in the case of the other hospitals. 

Special care was being paid to keeping latrines and urinals in a 
satisfactory sanitary state. 

The kit, bedding, and clothing of every man reporting sick with 
fever was set aside in a store reserved in each barracks for the purpose, 
until it could be disinfected. Spraying, steeping, and steam 
disinfection were the methods in use. 

A sample of blood was taken from each case of fever, and was sent 
to the laboratory for examination. 

On a case being diagnosed Mediterranean Fever, the sanitary officer 
and others concerned were immediately notified. 

If a second case of Mediterranean Fever was admitted from the 
same barrack room, the room was evacuated and it was disinfected by 
spraying, scraping, and limewashing. 



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Epidemiological Work in 1906. 215 

In hospitals, special feeding cups, urinals, and bedpans were set aside 
and marked for the use of Mediterranean Fever patients. 

Attendants on the sick had strict instructions to be careful as to 
personal disinfection, and there was a standing order that they were 
to wash their hands in a disinfectant and to use the nail brush 
immediately after handling bedpans, soiled bedding, and clothing, etc. 

Questions relating to the application of additional preventive 
measures were discussed with the Principal Medical Officer from time 
to time as occasion arose, and twice in conference with H.K the 
Governor. At the first of these conferences it was represented that, 
in order of importance, practical measures were : alteration of the milk 
supply; isolation of cases; disinfection; segregation and observation 
of contacts ; care that the men get their full 750 cubic feet space ; and 
attention to general sanitation. 

The Milk Supply. — The discontinuance of the use of goats' milk in 
barracks and hospitals was pushed at the end of April. It became an 
accomplished fact in hospitals by May 17, and in barracks between 
that date and June 7. The details have already been fully discussed 
<p. 166). 

Isolation of Cases, — Shortly before oiu* arrival in Malta the question 
of isolating cases of Mediterranean Fever in one hospital was raised 
by the Principal Medical Officer, and it had been decided to let it 
43tand over until the Members of the Commission arrived. After 
•discussion, it was decided to use Valletta Hospital, as it was centrally 
43ituated, and also because it was the most convenient from an 
administrative point of view. Accordingly, the hospital began to be 
xised for this special purpose from May 1, 1906. We recommend the 
continuance of the practice of isolating cases of Mediterranean 
Fever. 

As Valletta Hospital is situated in a densely populated neighbour- 
hood, where mosquitoes are generally plentiful, it was resolved to 
make the windows and doors of the wards mosquito-proof, so as to 
prevent the entrance of mosquitoes and the possible carriage of 
infection by them. The windows and doors of the rooms used as 
barrack rooms by the detachment of the Eoyal Army Medical Corps 
were also mosquito netted. We now think that, as infection is 
probably seldom, if ever, conveyed by mosquitoes, this measure was 
perhaps one that might have been dispensed with, although it 
certainly was useful in excluding mosquitoes and also flies. It was 
considered by the staff and by the nursing sisters that the mosquito 
netting, even although the windows were constantly open, interfered 
with the free passage of air and rendered the wards uncomfortably 
close. The same view was strongly held by the men with regard to 
the barrack room netting. On the whole, the balance of evidence is 
against renewing it. 



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216 Major McCulloch, Major Weir, and Staff-Surgeon Clayton, 

Segregation and Observation of Contacts, — The procedure recommendedT 
and which was adopted was as follows : — 

(1) To enable the disinfection of barrack rooms to be thoroughly 
carried out. The room was evacuated, and separate accommodation 
was found for the men until the disinfection of the room had been 
completed, after which they were allowed to return to it. 

(2) For the detection of ambulatory cases. The " contacts " were 
kept under observation and examinations for agglutination reactions- 
were carried out. 

(3) Men who had been discharged from hospital after treatment for 
fever were kept under observation. 

Examination of Blood of " Contacts " and others, — Five himdred and 
aeventy-f our samples of blood were examined during the year. . 

Thirty samples were taken from men of the 2nd Battalion Essex 
Begiment, who had had Mediterranean Fever in 1904 and 1905^ 
Twenty- eight gave a positive reaction against Mkfrococcus mdiiensis. 

Six ponies were examined as contacts, of which the blood of threa 
gave a positive reaction. 

Bloods from 140 Maltese, employed in barracks, were examined, of 
which 11 gave a positive reaction. These include one man whose 
seriun reacted against both Mia-ococcus melitensis and a paratyphoid 
bacilluSf and another man whose serum reacted against a paratyphoid- 
bacillus only. The last case was diagnosed simple continued fever*. 
Excluding this case, positive reactions were obtained in 7*7 per cent^ 
of the Maltese examined. 

Three hundred and seventy samples of blood from men of British 
troops were examined, 37 of which gave a positive reaction against- 
Micrococcus mAitensis — that is, 9*2 per cent. 

The blood of one British soldier gave a positive reaction against a. 
paratyphoid bacillus. 

The urine of 26 cases was examined for the presence of Micrococcus 
melitensis. It was recovered once from the urine of a married man^ 
whose wife contracted the disease during the summer of 1906. Her 
husband was a relapse from the previous year. The wife, no doubt, 
may have been infected from this source ; but both husband and wife 
drank goats' milk freely, so that possibility of milk infection cannot be. 
excluded. 

The blood of "contacts" of 18 families was examined. In three- 
a positive reaction was obtained ; all three were persons who never- 
manifested any symptoms of Mediterranean Fever. 

Positive reaction without symptoms was also observed in the case of 
four men of the Royal Engineers. Seventy-four samples of blood were» 
examined from men of this corps, and four gave a positive reaction 
against Min'ococcus melitensis. These four men had never been ill, and 
have not since manifested any symptoms of the disease. 



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Epidemiological Work in 1906. 217 

The dilutions used in the blood examinations were 1 in 10 and 1 in 
20. The examinations were made in the laboratory of the Mediter- 
ranean Fever Commission. 

From these examinations it appears that the bipod of individuals 
who have no history of previous attack, and who do not for long 
periods after manifest any apparent symptoms, may give a positive 
reaction. We understand by this phenomenon that certain persons may 
be invaded by Mia'ococcus meliiensis without showing any signs of illness. 

Although we were on the look out for cases in which the disease 
might have been contracted from ambulatory cases, and we also thought 
that special liability might be shown by men employed in keeping 
latrines and urinals clean, or in handling urine tubs, we failed ta 
observe any such cases. The three laboratory' cases, the three men 
who were admitted for Mediterranean Fever, and who were found to 
have been constantly grooming ponies the blood of which gave good 
positive reactions, the probability that goats themselves may be 
infected through breaches of the surface, make it evident that contact 
cannot altogether be disregarded. In view of the fact, however,, 
that close association with cases of the disease in the Home hospitals,, 
both as regards sick attendants and patients under treatment in the 
same wards for other ailments, has never been known to result in the 
spread of Mediterranean Fever, contact is probably an infrequent factor.. 

Disinfection, — Up to the middle of April, 1906, the practice was to 
carry out disinfection of kit and bedding in every case of Mediterranean 
Fever, but the room was not disinfected unless a second case occurred 
in it. This was altered to disinfection of the room on the occurrence- 
of the first case. If subsequent cases occurred, the bedding and clothing 
of the case was dealt with, but the room was not again disinfected 
unless required by special circumstances, and such, as a matter of fact, 
never occurred. The disinfection arrangements were carried into- 
effect under the supervision of the sanitary oflScer, Major Gray. 

Attention to General Sanitation, — A good deal of care was bestowed on. 
the condition of latrines, urinals, urine tubs, and urine tub stands on 
account of the possibility of such places being fouled by infected urine,, 
but, as we have just pointed out, we have no evidence of the spread 
of Mediterranean Fever in this way. It was suggested that latrine 
seats should be scrubbed daily with a 2^per-cent. carbolic solution, and 
that all other woodwork should be scrubbed once a week. In the cas& 
of dry earth closets, placing carbolic solution in the pails was recom- 
mended, and, to prevent spillage, that a spadeful or two of dry earth 
might be added to the contents before the pail was moved. Urine 
tubs and urine tub stands were to be kept scrupulously clean, and it 
was suggested that arrangements should be made for providing means 
for washing the hands of men employed on urine tub fatigues. Swarms 
of flies round ashbins were often noticed. This was caused by the 



Digitized by VjOOQ IC 



218 Major McCuUoch, Major Weir, and Staff-Siirgeon Clayton. 

contents getting strewn over the ground, through the doors being left 
open, and the covers left up. Flies were often observed to be abundant 
in kitchens, and especially in the places where cooking is carried on in 
the regimental coffee shops. This was usually due to grease stains 
about the tables or on the floors. Regular scrubbing keeps down their 
number largely. Flies were often present in large numbers in latrines, 
and we found an excellent plan in use in the St. Andrew's Barracks, 
namely, the application of a thin layer of kerosene oil once or twice a 
week to all woodwork about the latrine, except the seats. It does not 
take much, and these latrines were remarkably free from flies. 

Special Sanitary Staff, — At the time we left Malta, all the infantry 
units had adopted the plan of having the sanitary work in barracks 
done by a permanent staff of men, consisting of two men per company 
under the orders of the quartermaster, in place of the old practice of 
having one or two permanent men and having the greater part of the 
sanitary work done by fatigue parties. One or two of the quarter- 
masters informed us that they had found the change of the greatest 
help to them, and that they could get sanitary work more system- 
atically and, therefore, more efficiently done. 

11. Remits of the Work of 1906. 

The conclusions drawn from a critical examination of the military 
and naval observations are given in detail in the general summary 
(p. 244). It may be stated here, however, that the investigations 
relating to the garrison indicate : — 

1. That the goat is the primary source from which the disease is 
spread to man. 

2. That goats' milk is the common vehicle for the Micrococcus tneliteims. 

3. That flies may act as carriers. 

4. That the other paths of infection play but a minor part Contact 
and dust are possible, but probably very infrequent, factors, while the 
case for mosquitoes or other biting insects is not proven. 

The use of goats' milk is the one factor which has come into special 
prominence in the investigations of the probable causation of cases of 
the disease in 1906. A history^ of goats' milk was traced in 70*6 per 
cent, of the cases investigated up to the time we left Malta at the end 
of September. Those who are most in the way of using milk appear 
to be most liable to attack — for instance, officers are more liable to 
attack than men ; and, probably for a similar reason, a special liability 
appears to attach to certain occupations, such as cooks, officers' servants, 
and mess waiters. 

The cutting off of the use of goats' milk from barracks and hospitals 
has constituted an experiment on a very large scale, and one that has 
been, so far, attended by exceedingly satisfactory results, as will be 
observed from a study of the following tables and Charts 5 and 6 : — 



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Epidemiological Work in 1906. 



219 



f5 

3 



1.9 i •■ssl 



-°ll I 



H gt 






.91 « It- 



i & 

g .2 

I I 



I 






^1 1c 



-5 2 . 

.lis 



■sl 



^ 



I 












';tpoi^iH^pooa»iH 

iHrHiHOiHOiH^iHO 






S £r 22 3! 2 *:: « 3 5 fe 



CO ■<*• CO "* 5Bi-«t*«o 



^ll§§sgl§l 



§ig§isiisi 



ttSoaoSSodSSc 






fH faO 

-si 

IS 

• 4- 



Digitized by VjOOQ IC 



220 Major McCuUoch, Major Weir, and Staff-Surgeon Clayton^ 



70 



60 



50 



Monbhlti phevaJence - Rab1o5 per ipoo of strength 
expnee&ed in terms of an annual ratio. 
1899 Do 1905. 

Jan. Feb. Mar Apr May JMne Julij Aug Sept. Oct. Nov. Dec^ 



40 



30 



20 - 



lO - 











- 


- 








1 
















1 
i 

1 
























-- 








- -- -- 


-- -- 


- 


- - 


- 

- ( 



" 2^^ 23-8 \22-4 23-4 »4 'IC^ 4Cr4^-0 68-2 4&I \34-o\»-7 

Ratios per ipoo 



Temperature dund Rainfall Monthly means 1899 to 1905. 



ho 



H:50 







Tem'p. * 
R&irrfall.ii 


N.—— 




/^ 




^ 






I 

J 












/ 








\ 














y 


r 








\ 


\ 


, - ] 








y 


/ 












\ 


s_ 


^ 


,^ 


^ 














^'^^ 


,— 0— 


iv 




V, 


*«0— 


-0.- 


— 0— 








.v' 


r 




: 



8 8' 



Chart 5. — Mediterranean Fever amongst the troops in Malta. 



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Epidemiological Work in 1906. 



221 



-ro 



"Monthly prevalence — Ratios per ipoo of dtrengbh 

expreaaed in terms of an annual natio. 

1906. 

Jan. Feb., Mar Apr Majj June July Aug. Sept. Oct. Nov. Dec. 



40 



30 



AO 



JU>- 



10 



J 



I 



I 



t 



1 



fl 



B&tioe si^5 iM itf-z 2sy2, t£t 46-3 i/fyz ^ zte lo-i 65 4-1 
•per w>o,^^^ ^^ ^^^ 5Wt 42^ I6"4 35-7 40 ■Rea^'wwsiona 



•excluding neodmiesione. 

Temperature and Rainfall 



dhewn tihud. 
MonthiM meeuie 1306. 




Ghart 6. — ^Mediterranean Ferer amongst the troope in Malta. 



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222 Major McCulloch, Major Weir, and Staflf-Surgeon Clayton. 




Digitized by 



Google 



Epidemioloffic^l Work in 1906. 



223 



Table XVI shows the monthly prevalence of Mediterranean Fever in 
the Malta garrison during 1906. Tables XVII and XVIII give similar 
information regarding simple continued and enteric fevers. The average 
number of cases and the average ratios for the seven years' period 
1899 to 1905 are added in each instance for comparison. 

Table XVI. — Mediterranean Fever. 





1 


1 


1 


i 


i 


i 


i 


< 


September. 
October. 


1 
1 


1 


AdmiwionF 1906 ... 


26 


11 


16 


18 


80 


23 


11 


8 


11 


6 


8 


2 


Monthly average 


18 


15 


16 


16 


23 


28 


34 


45 


46 


84 


23 


17 


1809—1905 


























Batios— 
























1906 


86-8 
24-6 


17 -3 1 24 -2 


29-2 
28-4 


61-5 
32-4 


46-3 
40-6 


20-2 
46-4 


13-9 
63-0 


21-6 
68*2 


10-1 
48-1 


6-5 
34*0 


4 1 
28-7 


1899—1906 


23-8 


22-4 







Table XVII.— 


Simple Continued Fevei 


•• 










1 


t 


1 


t 


1 


i 


1 


1 


1 


1 
1 


1 


AdmiMions 1906 


5 


8 


4 


7 


9 


117 


185 


66 


61 


29 


15 


8 


Monthly aver- 


15 


11 


19 


23 


82 


164 


308 


212 


181 


69 


28 


18 


, age 1899— 


























1 1906 


























IBatioe— 


























! 1906 


7-4 
21-0 


3-2 
16-4 


8-0 
26-4 


6-5 
88 -2 


18-5 
457 


215*4 
288 1 


881*4 
426 1 


114*6 
297-4 


120*0 
266 7 


58-6 
97*0 


32-4 
38*2 


6 1 
19*2 


1899—1906 ... 



Table XVIIL— Enteric Fever. 





1 


l£ 


1 


April. 
May. 


»-s 


i 




1 


1 


November. 
December. 


Admissions 1906... 


1 




1 
- 1 4 8 





___ ■ 


1 








_ 


__ 


Monthly arerage 


8 


2 


8 1 1 ' 1 


3 


7 


6 


3 


5 


5 


5 


1899—1906 






1 1 














Ratiofr- 






1 1 




! 








1906 


1*5 


— 


— i6*5 6-2 


— 


— 1*8 


— 


— 


— 1 — 


1899—1906 


3*60 


8*28 


4*81 1-^ 1-81 


3 73 


10 08 8-61 


4*85 


7*85 


6-60'6-95 

1 



Digitized by VjOOQ IC 



224 Major McCiiUoch, Major Weir, and Staflf-Surgeon Clayton. 

The satisfactory character of the decreased prevalence obserred 
during the second half of 1906 is even better shown by tabulating the 
figures relating to Mediterranean Fever incidence by quarters (see 
also Chart 6). 

Table XIX. — Mediterranean Fever. 

Comparison of 1906 with the Period 1899—1905, by Quarters 
of the Year. 





January 

to 
March. 


April 

to 
June. 


July 
September. 


October 

to 

December. 


Admissions, 1906* ... 
Average for period 
1809—1905 

BatioB, 1906 


52 
49 

26-3 
28-6 


71 
67 

44-4 
82 1 


80 
125 

18-4 
58-9 


10 

74 

6-9 
85*8 


Average for period 
1899—1905 


! • 1906, excluding re- 

admissions^ — 
j Batios 22-2 


42-5 


15*4 


4-8 



While it is shown even better still by dividing the year into two 
six months' periods, and the more so because the first six months 
represents the period preceding the milk change, and the second six 
months the period after the milk change. 

Table XX. — Mediterranean Fever. 
Comparison of 1906 with the Period 1899—1905, by Half Years. 



1 
1 


AdmiBsions. 


Batiof per 1000. 


January 

to 

June. 


July 

to 

December. 


Januaiy 

to 

June. 


July 

to 

December. 


1 

1906* 


128 
116 


40 
199 


84-1 
27-6 


18 1 
47-6 


Average for period 
1899—1906 


• 1906, exctluding re- 
admissioQS 


112 82 


81-0 


10-5 



In the two units which showed most prevalence in 1906 the disease 
was practically confined to the first half of the year. 



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Epidemiologic(d Work in 1906. 
Ist Battalion Boyal West Kent Regiment. 



225 



1 


1 


A 


t 


1 


1^ 


i 


1 


1 


1 


1 


1 


1 


8 


6 6 


8 


10 


— 


2 


2 


— 


— 


— 



See also remarks at the end of the discussion of the cases which 
occurred in this regiment (p. 192). 









Soyal Army Medical < 


Dorps 










•^ 


1 


1 


% 


1 


Hi 


% 

^ 


^ 


i 


1 


i 
1 


1 


8 


8 


1 


8 


6 


1 


— 


— 


2 


— 


— 


— 



See also remarks (p. 200). 

The prevalence amongst officers was also chiefly confined to the first 
six months of 1906. 

Officers. 



1 


1 


J^ 


t 


1 


>? 




-3 


1 


1 


1 
1 


1 


— 1 


1 


2 


2 


2 


1 




— 


' 


— 


— 



The prevalence amongst soldiers' wives is not so strictly confined to 
the first half of the year, and the figures for the children are nearly 
-equaUy distributed between the two halves of the year. It is difficult 
to control the introduction of goats' milk into married quarters. The 
last two cases amongst the women, reported in November and December 
respectively, used goats' milk. The Principal Medical Officer, Malta, 
makes the following comment regarding one of these cases : — " I find 
that in spite of personal warnings and the prevention of goats entering 
barracks, married people persist in obtaining goats' milk outside." 
•Commanding officers are communicated with when such cases come 
under observation. 

(2089) 2 



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226 Major McCuUoch, Major Weir, and Staff-Surgeon Clayton. 



Soldiers' Wives. 



r 
1 


1 


1 


April. 
May. 
June. 
July. 


August. 
September. 


1 


1 
1 


December. 


— 


1 


— 


8 1 7 


1 2 


1 


2 


— 


1 


1 



Children. 



I 



I 



a* 



i 



a 

H9 






4 



I 



I 
o 



I 



8 - 



1 — 



It may be reasonably claimed that since the use of goats' milk was 
discontinued in barracks and hospitals there has been a great reduction 
in the prevalence of Mediterranean Fever. This is well shown in 
Tables XIX and XX and Chart 6. By a glance at Chart 6 it will be 
observed that Mediterranean Fever showed more than average prevalence 
during the six months of 1906, in comparison with the corresponding 
months of the seven years' period 1899 — 1905. This seemed to presage 
that in the second half of the year, the period when the disease is 
generally at its worst, more than ordinary prevalence was to be expected, 
instead of which the very reverse has happened. Concurrently there 
has also been a reduction in the admissions for simple continued fevers, 
which was also most marked in the second half of the year. We 
may have here foreshadowed the decline of Mediterranean and simple 
continued fevers in Malta, just as we have already seen in the first 
part of this report that their disappearance from Gibraltar was also 
simultaneous in character. 

It is, of course, impossible to build upon six months' results as on a 
sure foundation. If, however, the milk change is the true explanation 
of the reduction, it will stand the test of time, and by that alone can 
the importance of goats' milk as the chief causative factor be 
established. But it must, at the same time, be remembered, that^ 
unless the dangers of infected goats' milk are being constantly kept in 
view, and constantly brought to the notice of sbldiers and soldiers^ 
families, there is always the possibility of lapse to old ways, with ita 
attendant risks of spread of the disease. 



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Hpidemioloffical Work in 1906. 



227 



Division III.— CIVIL. 

We do not propose to enter upon a detailed discussion of the 
prevalence of Mediterranean Fever amongst the civil population. 
Accurate information is difficult to obtain, and the subject of civil 
prevalence has already been dealt with by Dr. Johnstone in the 1904 
Eeports, together with topographical details and a general sanitary 
survey of the Maltese islands. We accordingly limit ourselves to 
bringing distribution tables up to date, and to a brief discussion 
of some of the more important points connected with the disease 
as observed amongst the civil population. 

1. Prevalence of the Fever among the Civil Population. 

The following table shows the monthly distribution of cases in 1906, 
compared with the average monthly prevalence during the 10 years 
1896 to 1905 :— 



Table I. — Civil Population. Monthly Distribution of Cases in 1906. 





g 


1 


A 


1 


1^ 


^ 


^ 


i 


ll 


1 


eoember. 
otal. 




A 


N 


« 


< 


>i 


H9 


Hi 


< 


c8 |0 


^ 


P H 


Ayerage — 
1896—1905 


82 . 26 


i 

30 1 30 


1 ' 
48 1 68 87 


87 


69 64 52 49 682 


1906 


20 27 


28 I 54 


81 109 108 


108 


71 32 87 28 698 



This table shows that cases of Mediterranean Fever are notified 
all through the year, and that there is an increase in the notifications 
during the hot weather months. 

The notifications for 1906 showed increased prevalenpe up to the 
end of September, after which they are below the average during the 
three last months of the year. The improvement indicated by the 
figures for the last quarter may possibly be the result of the attention 
of the public having been largely drawn to the dangers of goats' milk. 
This has been helped by articles in the local press, and also through 
a pamphlet issued by the Public Health Department. Public interest 
in the matter was also roused by the strike of the goat-herds in the 
last fortnight of May, and we are informed that, during the closing 
months of the year, the attention of the public has also been called to 
the subject by the clergy. 

(2089) q 2 



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228 Major McOuUoch, Major Weir, and Staflf-Surgeon Clayton. 

2. Age and Sex in BekUion to Attack. 

The relation of age and sex to the occurrence of Mediterranean 
Fever is shown in the following table : — 

Table II. 



Yean. 


July 1, 1904-^une 80, 1906. 


July 1, 1906— June 30, 1906. 
















liales. 


Females. 


Total 


Hales. 


Females. 


Total 


1— 6 


6 


11 


17 


18 


6 


19 


6—10 


18 


28 


41 


26 


24 


40 


11—16 


28 


48 


71 


84 


86 


69 


16— ao 


64 


61 


106 


62 


40 


111 


21—26 


66 


60 


106 


71 


46 


117 


26—80 


40 


40 


89 


46 


68 


98 


81—86 


81 


28 


69 


81 


29 


60 


86—40 


26 


20 


46 


29 


80 


69 


41—46 


21 


16 


87 


20 


80 


60 


46-60 


16 


21 


87 


19 


18 


87 


61—66 


14 


16 


29 


18 


16 


34 


66-60 


7 


16 


28 


20 


16 


36 


61—66 


8 


6 


18 


12 


7 


19 


66-70 


9 


4 


18 


4 


2 


6 


71—76 


— 


— 


— 


6 


2 


7 


76—80 


1 


— 


1 


1 


1 


2 


81—86 


— 


— 


— 


1 


1 


2 


86—90 


1 


^^ 


1 


"" 


— 


— 


Total... 


840 


848 


688 


410 


864 


774 



It will be observed from Table II that the disease may occur at any 
age, but that it was most common amongst persons between 10 and 
30 years of age. A case was observed in the garrison during the year 
in which a baby was bom at the time the mother was in hospital for 
the disease, and the infant had a temperature the curve of which 
corresponded almost exactly to that of the mother. Of 1462 notifica- 
tions during the two years, 750 were males and 712 were females. 
The sexes would, therefore, appear to be about equally liable. 

Oase Mortality. — The case mortality for the 10 years 1896 to 1905 
works out 9*5 per cent, as compared with 3*3 per cent, for the garrison. 
The returns of mortality to attack have shown progressively increasing 
figures during the last three years, as under : — 

Percentage of deaths 
to cases notified. 
1902—03 (April 1— March 31) ... 8-1 

1903—04 10-3 

1904—05 13-2 

1905—06 14'2 



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Epidemiological Work in 1906. 229 

This increase is attributed by the Chief Oovemment Medical OfiScer 
partly to cases of enteric fever having been reported as Mediterranean 
Fever, and partly to the return of cases as Mediterranean Fever which 
would have been formerly otherwise classified. He bases these 
assumptions on the fact of the general death rate showing decrease, 
and considers, therefore, that the increase observed in the death rates 
from fevers is chiefly a transfer of figures from other heads. The high 
case mortality indicates that a great many cases of Mediterranean 
Fever occur which are not notified. It is possible that many cases do 
not come under observation at all, and we have met with other 
instances in which notification has been delayed till the patient was at 
death's door. It must be remembered, too, that blood examinations 
are the exception and not the nile. 

Irregular Prevalence of the Disease in Toums and Villages, — ^As pointed 
out in the military part of the report, there is great variation from year 
to year in the incidence of the disease in different barracks, so it will 
be observed from consideration of the figures in Dr. Johnstone's report, 
Part II, Commission Reports, p. 18, that similar variation of prevalence 
is also observed in the case of the civil communities. For example, 
the Floriana district shows more than the average number of notifica- 
tions in 1896, 1899, 1904, and 1905, while the nmnber was low in 
1895 and 1898, and moderate in 1901 and 1902. Birchircara appears 
to have had an unusual prevalence of cases in 1899 as compared with 
other years. Notabile and Eabato had large prevalence in 1899, and 
we have already seen that there was a sharp outbreak of the disease in 
that year in the neighbouring Imtarfa Barracks. Zebbug had large 
prevalence in 1896, 1900, 1902, and 1905, but the notifications were 
much fewer in 1897 to 1899, 1901, and 1904. The differences are so 
very marked as to point to a factor which is liable to irregular varia- 
tion, rather than to the presence of a condition or conditions of a more 
permanent kind, and it is thought that an infected milk hypothesis 
seems best to explain these variations. 

Distribution of Mediterranean Fever in Malta, — Table III shows the 
distribution of the disease in the towns and villages during the two 
years irom July 1, 1904, to June 30, 1906. For purposes of com- 
parison, the first column gives the ratios per 10,000 of the population 
for the 10 years' period 1894 to 1903, which are taken from Dr. John- 
stone's report. 

This table shows : — 

1. The very general character of the distribution of the disease 
amongst the towns and villages of Malta. 

2. That while the prevalence in the rural areas remains fairly steady, 
there has been an increase in the notifications in the urban and 
suburban areas. It is impossible to say whether this increase is due 
to greater prevalence of Mediterranean Fever or to the greater 



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30 Major McCuUoch, Major Weir, and StaflF-Surgeon Clayton. 



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Upidemiological Work in 1906. 



231 



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Digitized by VjOOQ IC 



232 Major McCulloch, Major Weir, and Staflf-Surgeon Clayton. 

attention which has been paid to the disease during the last three 
years having caused more cases to be diagnosed and notified. It has 
to be remembered that blood examinations are not a routine proceeding 
in connection with civil cases, the diagnosis being mostly determined 
by the clinical features of the cases. 

3. That the surburban districts have always shown a greater number 
of cases than the urban districts. Several points arise for considera- 
tion in this connection : 

(a) Nearly all the places included irnder "suburban areas" are 
now drained, so that absence of drainage does not explain the heavier 
incidence. 

(b) The disease does not show any marked preference for places 
having an indifferent sanitary reputation. During the two years 
July 1, 1904, to June 30, 1906, Sliema, which is a newly built suburb, 
well situated, with good streets and houses, good drainage, a satis- 
factory water supply, and containing the residences of a large 
proportion of well-to-do people, has been marked among the suburban 
districts by the highest prevalence of the disease. The sanitary 
conditions in Sliema are in marked contrast to the conditions obtaining 
in Misida, and yet the prevalence of the disease is about the same in 
the two places. Again, Birchircara and Cimni have frequently been 
contrasted, the former having a good reputation from a sanitary point 
of view, but a bad reputation as regards prevalence of Mediterranean 
Fever, while the conditions are the exact reverse in the case of Ciurmi. 
A possible explanation may be that there is a greater consumption of 
goats' milk in Birchircara than in Curmi. Table III shows that, with 
practically equal populations, there are nearly three times the number 
of goats in Birchircara than in Curmi ; and, f luther, Curmi contains 
a much larger proportion of very poor people, and the poor are not 
large consumers of milk, as it is for them an expensive commodity. 

(c) Although it often appears that density of population seems to be 
attended by marked incidence of Mediterranean Fever, yet this is far 
from being always the case. It will be observed (Table III) that 
Zebbug, which is one of the least densely populated places, displays, 
more than average prevalence during the 10 years' period 1894 to 
1903, and also in the second of the two years under consideration^ 
although it was under the average in the first of these years. In the 
urban areas the same is observed. Floriana, which is much more open 
than Valletta and less densely peopled, shows more than three times 
the incidence of the latter for the decennial period and for the two 
years under special consideration. The Manderaggio, which is one of 
the poorest and most densely populated parts of Valletta, with a 
population of about 3000, and is also one of the worst parts 
from a sanitary standpoint, has only had five cases of Mediterranean 
Fever reported from it during the two years, two in 1904 and three in 
1905. 



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Epidemiological Work in 1906. 23$ 

3. The Relation of Goats to the Incidence of the Disease, 

With a view to see whether any relation existed between the number 
of goats and the incidence of the disease in towns and villages, a 
special enumeration of the goats in Malta was made at the end of 
June, 1906. This was rendered possible by the fact that every goat 
owner has to register, at regular intervals, with the police, information 
regarding the nimiber of goats he possesses. The figures are given in 
Table Illf but we can draw no exact deductions of a general kind front 
the information so obtained. It is of interest to note, however, that 
a very large number of goats are kept in the suburban districts, 
which, as already pointed out, are also marked by the greatest 
incidence of Mediterranean Fever. It is from these suburban herds, 
that the milk supplies of Valletta, Floriana, Sliema, and the three 
cities are chiefly obtained. Hamrun, Birchircara, and Misida provida 
the supplies for Valletta, Floriana, and Sliema, while the Zabbar,. 
Tanden, and Paula goats supply Cospicua, Vittoriosa, and Senglea. 

Exportation of Goats from Malta, — A large number of goats are 
exported from Malta each year, chiefly to Sicily and NorUi Africa.^ 
In the two years from July 1, 1904, to June 30, 1906, the numbers- 
exported were 1911 goats, 20 kids, and seven billy goats. In this 
niunber are included the goats shipped in the s.s. '* Joshua Nicholson,'** 
which, as related elsewhere, led to an outbreak of Mediterranean 
Fever on that ship and to the occurrence of cases in the United 
States. It is evident, therefore, that the exportation of goats is 
attended by the danger of the spread of the disease in the places to- 
which the animals are consigned. As already mentioned in the: 
military part of this report, Horrocks has pointed out that in 1883,. 
when Mediterranean Fever was prevalent in Gibraltar, practically all 
the goats on the Rock were Maltese, and that regular shipments of 
goats from Malta to Gibraltar took place at that time. Shortly after 
1883 there was an increase in the cost of shipment, which led to the 
stoppage of the importation of goats from Malta on a large scale 
and, coincident with this, the disease has practically disappeared from 
Gibraltar. 

MUk in Belaiion to Incidence among the CivU Fopulaiion. — The milk 
supply of the civil population is goats' milk, and it is generally used 
unboiled. In some cases the milk is obtained regularly from the same 
goat-herd ; in others, and this is very common, the milk is bought from 
any passing herd, while others again keep one or sometimes two goats, 
of their own. We have been informed that many poor people do not 
use milk at all except when it is required for cases of sickness. 

During the last two years, special enquiries were made by the 
sanitary inspectors with regard to the source of the milk used by 
patients notified as suflering from Mediterranean Fever, and the 



Digitized by VjOOQ IC 



234 Major McCulloch, Major Weir, and Staff-Surgeon Clayton. 

results are as follows. Of the 1462 cases notified, no particulars could 
be obtained in 68 instances. In the remaining 1394 cases, goats' milk 
was used by 1318 of the patients, condensed milk in five instances, 
while there is a history of no milk in any form in the remaining 
71 cases. 

Table III shows that Lia, Attard and Balzan usually exhibit a 
heavy prevalence of the disease. Two hundred and three of the 
^oats at Lia and Balzan were examined in 1905, and 31 were found to 
be infected. The Chief Government Medical Officer, Dr. Caruana 
Scicluna, has provided a good piece of negative evidence in connection 
with the Institute of the Good Shepherd at Balzan. He states that 
there has not been a single case of fever amongst the 200 inmates of 
this institution for many years past. The goats supplying the milk 
are the property of the Institute, and when examined they have been 
found to be iminfected. 

Further details with regard to goats* milk as a factor in the 
<;ausation of Mediterranean Fever amongst the civil population are 
given in the paper contributed by Dr. A. Critien, of the Public Health 
Department, Malta, p. 235. 

Control of Goats and of the MUk Supply. — It follows, from a con- 
sideration of the dangers of infected goats' milk, that the most 
imperative need is the regulation of the goat traffic and proper contnd 
of the milk supply. The goats should be kept outside the towns, and 
Stable arrangements made for bringing the milk in to be sold. In 
Malta it is urged that the poor people prefer to have the goats 
brought to their door and there milked, because they can then see 
what they are getting, and there is less chance of adulteration. But 
43urely this is a prejudice that can be overcome. In no other civilised 
community is the source of the supply brought to the consumer's door 
to be milked, and there is no greater likelihood of adulterated milk 
being vended in Malta than exists in every other place of importance 
in the world. Everyone who is familiar with the streets of Valletta is 
also familiar with the smell of these streets. The objectionable smells 
^re entirely due to the perambulation of the streets by herds of goats. 
In every gutter are to be seen collections of goats' urine, and these and 
the goats themselves are the causes of the foul odours. A great 
object-lesson was furnished to the inhabitants of Valletta during the 
fortnight that the goat-herds' strike lasted. There were no goats in 
the town during that period, the streets were clean, and the bad smells 
•disappeared completely. The extraordinary improvement in the state 
of the streets was the subject of common remark at the time. As 
soon as the goats returned, tBe smells became as bad as ever. There 
•can be no doubt about the fact that if the goats were excluded from 
the streets, Valletta would be as clean and pleasant as any well-run 
town in Europe. Until the goats are removed the condition of the 



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Epidemiological Work in 1906. 235 

streets must continue to be a reproach, and Valletta must be regarded 
as being content with a sanitary standard which is far below what it 
might be. 

Improved Sanitation. — Otherwise, considerable improvements have 
been made during the last t^o years. Young men are being sent to 
England to be trained in the duties of sanitary inspectors. Very fine 
public urinals have been erected in diflFerent parts of Valletta. In 
company with the Director of Public Works, we went over the entire 
drainage system, including the pumping arrangements at Sliema, the 
flushing tank at Lower St. Elmo, and with Dr. Zammit we visited the 
sewage outfall to the sea beyond Eicasoli. We also saw the new 
Shone installation for dealing with the low-level drainage of the low- 
lying parts surrounding the upper end of the Grand Harbour and 
along its Valletta side. The work in connection with this new system 
was almost completed, but was not yet in use when we left Malta at 
the end of September. There is another large project in course of 
construction, which has for its object the flushing of the entire 
sewerage system of Malta with sea water, including outlying towns 
and villages as well as Valletta and the three Cities. The main 
supply tank has been excavated, and to this sea water will be pumped, 
and from it the flushing water will be distributed by gravitation. It 
will be a considerable time before the pumping plant is installed, and 
it will necessarily take time to connect up to the various lines of 
drainage. When completed, it will be a sanitary advance of great 
importance. If, at the same time, it were possible to combine with it 
a free supply of water for flushing from the houses through the 
house drains into the main drains, there would be little fault to find 
with the sewerage of Malta, although there would be still room for 
great improvement in regard to house fitments and connections. 

4. Ooat$^ Milk as a Factor in the Causation of Mediten-anean Fever amongst 

the Civil Population. 

By Dr. A. Critien, Public Health Department, Malta. 

The recovery of Micrococcus melitensis from goats* milk has very 
naturally directed the epidemiologist's activity to a new line of 
investigation which, if attended with positive results, must put 
Mediterranean Fever in a great measure within the reach of preventive 
medicine. The facts collected and the work done in this direction, 
during the last few months, have established that infected milk, though 
not the only channel, plays a very important part in the transmission 
of the disease. The following few observations, abstracted from the 
results of personal inquiries into 245 notified cases of Mediterranean 
Fever, are therefore intended only as a small contribution towards the 
study of this question. 

The milk used in Malta is goats' milk ; the number of milch cows in 



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236 Major McCulloch, Major Weir, and Staflf-Surgeon OlaytoiL 



the island is too small to be taken into consideration. The consumption 
of milk has during the last few years been steadily increasing, both in 
town and in the country ; and though in the villages it is far from 
rare to find persons who absolutely refuse to drink milk, in the towns 
and suburbs such perhaps are only exceptionally met with. Milk ia 
not boiled; this precaution has hitherto been considered superfluous^ 
because the Maltese goat has never been known to suffer naturally 
from tuberculosis; bovine tuberculosis, it must be remembered, has 
been mainly responsible for the continental routine of milk sterilisation 
by boiling. 

Milk is generally drunk with tea or coffee, the proportion of milk 
varying with the means of the particular individual. Weak digestive 
organs, the result of higher civilisation and of a harder struggle for 
life, have for obvious reasons contributed to increase the consumption 
of fresh milk, an item, moreover, which enters largely into the diet of 
the yoimger members of the population. Some of the foregoing 
statements are supported by figures shown in Table " A," from which 
we see that the number of goats in Malta has doubled during the last 
15 years ; but the population has not increased in the same proportion ; 
whilst in 1891 there was one goat for every 17 persons, now there is 
one for every 10. 

Table A.— Malta, 



Year. 




Number of miloh 
goftta. 


Proportion of goate 
to persons. 


1891 

1901 

1906 


146,484 
164,962 
183,231 


8,724 
10,944 
17,488 


1 in 17 
1 in 16 
1 in 10 



Out of 511 cases of fever notified as Mediterranean Fever from the 
beginning of January to the middle of August, 1906, 1 have been able 
to in^ct premises where 245 cases had occurred and to interview 
either the patients themselves or some relative. 

The information collected with regard to the use of milk may be 
tabulated as follows : — 

Table B. 



i 

No Condensed 
milk. milk. 


Cows' 
milk, 
boUed. 


Goats' 
milk, 
boUed. 


GhMite' 

milk, 

unboiled, 

by itself. 


Goats* 

milk, 

unboiled, 

with tea. 


Goats' 
milk, how 
used not 

aeoer. 

tained. 


60 1 6 


8 


6 43 


108 


36 


68 


187 



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Epidemiological Work in 1906. 237 

The proportion of fever patients who are milk-users to non-milk or 
other milk-users may, therefore, be calculated as 3 to 1. As my 
investigation was not limited to fever cases in the towns, but extended 
to cases in the villages and suburbs, this proportion may be regarded 
to obtain generally amongst all persons suffering from the fever in 
Malta. 

Out of 315 cases of fever notified from August to December, 1905, 
26 occurred in premises where one or more goats were kept and, with 
few exceptions, had supplied milk to the patients before illness. Out 
of the 511 cases notified between January and August, 1906, 67 
occurred under similar circumstances, 30 occurring amongst herdsmen. 
The 67 cases were distributed as follows : — 

Omm. 

50 dwellings with 1 case in each 50 

3 „ 3 cases in each 9 

2 „ 4 „ 8 

Total 67 

Of the 26 cases in the August to December, 1905, series, nine were 
amongst herdsmen. Ten cases notified from the village of Lia during 
that period may be thus classified : — 

Three in one herdsman's family. 

Four in households supplied with milk by this herdsman. 

Three milk supply not ascertained. 

Altogether seven members of this herdsman's family were down with 
fever during 1905. 

Some of the information collected about 25 of the 67 cases mentioned 
above is given in Table " C." Those instances only have have been 
recorded in which the goat or goats had been penned in the same house 
or compound where the cases occurred. 

In connection with 17 of these, the milk supply was examined 
bacteriologically. I regret that such a research, owing to stress of 
other work, could not be extended to all the cases. Three of these 
17 cases occurred in the same house, so that the number of instances in 
which milk supply was found to react to Zammit's test may be put 
•down as 7 out of 15, and the Micrococcus melUensis was isolated in 3. 

The milk supply was examined in connection with another series of 
25 cases which had been regularly supplied, previously to their illness, 
with milk by one or more milk herds. Results are given in Table " D." 
This is by no means a selected series, although a short one. The 
difficulty met with in trying to identify the milk supply in the 
majority of cases personally investigated has so far frustrated my best 
efforts. As the milk is hawked in the streets, many persons get their 
milk from the first milkman who happens to be about at the time milk 



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238 Major McCulloch, Major Weir, and Staflf-Surgeon Clayton. 



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Epidemwlogiecd Work in 1906. 



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240 Major McCulloch, Major Weir, and Staff-Surgeon Clayton. 



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242 Major McCuUoch, Major Weir, and Stafif-Surgeon Clayton. 

is required. Many again, who get it regularly from the same man, 
cannot remember anything more than his Christian name. Others are 
very reticent, because they cannot understand, why the milk they 
have been consuming for months without any ill effects should be 
suspected of being the cause of Mediterranean Fever. 

Four groups of cases shown in Table " D '^ had a common milk supply. 
Two cases in the first group occurred in the same dwelling ; the third 
group — five cases— had also a common residence, and the same was the 
case as regards the fourth group. In six instances the milk supply was 
found to be actually infected, viz., one or more goats were at the time 
excreting Micrococcus melUensis with their milk ; in two instances one 
or more goats gave Zammit's reaction, but did not yield Micrococcus 
meliiensis on the particular day they were examined, and in three 
instances none of the goats reacted. Six cases out of the first series of 
eight having a common milk supply occmred in the same street. 

The milk supply of another series of seven cases, not included in the 
245 investigated by me, was also examined. In one instance Zammit's 
reaction was obtained (Table " E "). 

A striking contrast to the heavy incidence of Mediterranean Fever 
among the general population is offered by the absence of the disease in 
communities that do not use milk. The Civil Prison, with its average 
daily population of about 185 persons of different sexes and ages, is an 
example. No milk under any form is allowed to the prisoners unless 
they are on the sick list. The average daily sick for the year 1905 — 6 
was 24'9. Under these circumstances, although the prison may be 
said to form part of Paola, a village which is by no means free from 
Mediterranean Fever, only one case has been recorded during many 
years. This case reported sick on May 8, 1906; his blood, which was 
negative on the 16th of the same month, reacted well in 1 in 40 
against Micrococcus mslUensis on June 6 when he first sickened. Less 
than a month had elapsed since his commitment, and if he had 
not been detained some time at Gozo, the sister island, before his 
transfer to the Malta gaol, one would have been quite justified in i 
doubting whether the disease had been contracted in prison. Another 
case, notified from the same prison in 1903, must have been 
infected when at large, because he had only been in prison three 
days when he developed Mediterranean Fever. So that, except 
for the case previously mentioned, the disease has been unknown 
among this community. Both the present medical officer and his 
predecessor agree in stating that during the time they fauve had 
medical charge of the prisoners — a period of nine years — no other cases 
of Mediterranean Fever have come under their observation* The only 
channel of infection that has been inoperative all through these years 
is goats' milk. Dust contaminated with infected urine must have been 
blown many a time from the streets of I'aola into the prisoners' cells, 



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Epidemiological Work in 1906. 243 

and mosquitoes, another suspected carrier of infection, cannot have 
found it difficult to fly from the village houses to the prison compound. 
One cannot, therefore, help connecting the absence of Mediterranean 
Fever with the absence of milk from the prisoners' dietary. 

Human milk, like goats' milk, agglutinates the specific micrococcus, if 
obtained from Mediterranean Fever patients. The highest dilution 
Mtended with positive results has been, in one of my cases, 1 in 150 
within half an hour. It does not appear that human milk is likely to 
react in the same high dilutions as some blood sera. Although I have 
not been successful in isolating Micrococcus Tnelitensis from human milk, 
its transmission from mother to child, through this channel, has been 
actually demonstrated by Major McNaught, RA.M.C., so that the 
danger of the disease being thus conveyed must not be lost sight of. 

The quantity of milk obtained from three out of my seven cases 
was very small (one to two drops), and no plating was, therefore, 
attempted; the plates prepared from the rest were so overgrown with 
other bacteria that the identification of Micrococcus melitensis was 
rendered impossible. 

A few notes about the cases will not, I hope, be found superfluous. 

1. M. P., aged 30. Baby 4 months old. FeTor began a few days after confine- 
tnent. Milk thin and serous ; it reacts within half an hour in a dilation of 1 in 20. 
Blood reacts well. Specimen of baby's blood could not be obtained. 

2. E. C, aged 30. Baby 3 months old. Feyer began before confinement. 
Breast almost dry, one or two drops of rery thin fluid obtained : it reacts within 
half an hour up to 1 in 80. Blood reacts 1 In 40 at once ; higher dihitions not 
tried. 

3. Q-. F., aged 24. Confined three weeks before ; baby weaned. Breast drying 
up. Few drops of curdy fluid obtained ; it reacts up to 1 in 40 at once. Blood 
reacts well in same dilution ; higher dilutions not tried. 

4. C. Z., aged 40. Onset of ferer one month after childbirth; nursing baby 
4 months old. Milk has diminished in quantity and is Tery thin. It reacts only 
up to 1 in 20 in half an hour. Mother's blood reacts well in 1 in 40. Baby's 
blood does not react ; only 1 in 10 tried. Milk plated ; no Micrococcus melitensis 
recoyered. 

5. C. F., aged 21. Ferer started one month before confinement. Baby was 
given out to nurse, and is now 2 months old. Milk reacts readily up to 1 in 150 in 
half an hour. Blood reacts well 1 in 40. A few drops of milk plated. No 
Micrococcus melitensis recoyered. 

6. F. 0-., aged 24. She is nursing baby 9 months old. Ferer began three 
months after confinement. Blood reacts welL Milk posiiire up to 1 in 20 in half 
«n hour. Plated ; no Micrococcus melitensis recovered. Specimen of blood from 
baby was refused. 

7. 0. B., aged 22. Fever began a fortnight after confinement. Baby is now 
4 months old. Milk reacts only 1 in 6 in half an hour. Blood reacts at once in 
1 in 40. Specimen of baby's blood was refused. Milk plat«d; no Micrococcus 
tnelitensis recovered. 



(2089) r 2 

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244 Major McCiilloch, Major Weir, and Staflf-Surgeon Clayton. 

General Summary. 

By Major T. McCulloch, M.B., Major J. C. Weir, M.B., Roya 
Army Medical Corps ; and Staff-Surgeon F. A. H. Clayton, M.D.^ 
Royal Navy. 

i. The incubation period. 

ii. A critical examination of the naval, military, and civil 

observations, 
iii. Recommendations. 

i. The Incubation Period. 

In the previous epidemiological reports it has been customary to» 
discuss the question of incubation period at the commencement, in 
order to fix working data. This course has not been followed on the 
present occasion, as in the investigation of cases it was fotmd that to 
keep rigidly to any fixed period was often impossible. In a very con- 
siderable proportion of the individual cases investigated there has been 
a sort of preliminary canter of a few days' pyrexia, but without 
agglutination reaction, followed later by a definite appearance of 
Mediterranean Fever. In many other cases the patients have felt 
vaguely ill for months. Again, many patients, admitted to hospital 
for other illness, have exhibited towards the latter part of their stay 
a few days of febrile and other symptoms, with no very obvious cause^ 
and shortly after leaving hospital they developed Mediterranean Fever. 
Similarly, many of those who developed the disease while still resident 
showed the same history of preceding slight febrile attack. All this 
points to the very insidious nature of the onset of this disease and to 
the difficulties encountered in fixing the limits of an incubation period,, 
and in saying whether an outburst of symptoms is, or is not, the first 
manifestation of the disease. Nothing would have answered our 
purpose better than to have been in a position to apply a definite 
period of incubation to the date of onset of symptoms, and so fix 
with some degree of certainty the time within which infection must 
necessarily have occurred. Much suggestive information on this point 
was obtained in the course of our work and from the study of 
statistical data, particularly data relating to the interval between 
residence in hospital for other illness and onset of symptoms of 
Mediterranean Fever, and in regard to the onset of illness occurring 
in cases after the men had left Malta. 

Accidental or purposive laboratory inoculations appear to show an 
incubation period varying between five and 16 days. Dr. Johnstone 
gives his views with regard to the matter in the following words : — " It 
may, however, be provisionally stated that the data available tend in 
some degree to suggest that the period of incubation of Mediterranean 



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£pide7)iiological Work in 1906. 245 

Fever ranges about a period of 14 days." Lieut-Colonel Da vies con- 
siders that there is a sufficient agreement in the results of animal 
experiments to lead to the supposition, which is on other grounds 
reasonable, that with infection by inoculation the incubation period 
IS shorter than by ingestion into the alimentary canal ; and this appears 
to be borne out by the results of the feeding experiments this year, 
no monkey so experimented upon having had an incubation period 
of less than 12 days. In connection with this subject, it is of interest 
to note that, this year, when the infected food was limited to one day's 
feeding, the appearance of the agglutination reaction varied from 12 
to 21 days, as opposed to 14 to 76 days obtained last year as the 
results of feeding experiments in which infected food was given over 
many days. It has been suggested by the laboratory members of this 
year's working party that a probable explanation of the delay in the 
appearance of the agglutination reaction observed in last year's 
experiments would be that repeated doses of Micrococcus melitensis pro- 
duced a negative phase, which lasted tmtil the cessation of feeding or 
an absence of the micrococcus permitted the formation of the specific 
agglutinins. Viewed from the epidemiological standpoint, the same 
reasoning may possibly explain the very late appearance of the agglu- 
tination reaction in certain typical and atypical cases of the disease, in 
which milk has been ingested over considerable periods, and who, there- 
fore, may have been receiving repeated quantities of Micrococcus melitensis. 
We associate ourselves with the view expressed by Lieut.-Colonel 
Davies, in Part lY of the Commission Eeports, to the effect that the 
laboratory limits in all probability require to be considerably extended 
when the question of human infection in the ordinary way, or ways, 
has to be dealt with. To this certain of the facts, already recorded, 
would seein to point, and, in fact, we quote well authenticated cases 
where the interval between possible exposure to infection and the 
onset of definite symptoms runs even to months. 

The cases which present difficulty in this direction fall under three 
•categories : — 

1. Cases presenting suggestive symptoms, but where agglutination 
is long delayed. These are so comparatively common that further 
•discussion is unnecessary. 

2. Cases presenting well marked agglutination reaction, without 
symptoms and without history of previous illness. Shaw's observations 
have already shown that the Maltese are sometimes definitely infected 
by Micrococci's melitensis without the slightest apparent effect on their 
j^eneral health. During the blood examinations of healthy English 
<;ontacts this year {vide p. 216), instances were from time to time met 
with which were strongly suggestive of the occurrence of this con- 
dition in their case also. The following are examples : — 

Two boys, belonging to the garrison, whose father and mother were 

Digitized by VjOOQ IC 



246 Major McCuUoch, Major Weir, and Stafif-Surgeon Clayton. 

both admitted for Mediterranean Fever in the summer of 1906, gave 
good serum reactions on repeated examinations. There was no previous 
history of fever, nor have either of these boys suffered from even a 
transient illness subsequently. In many instances, during the routine- 
examinations of samples of blood from soldiers who had been in 
*^ contact " with a case of the disease, a positive reaction was obtained^ 
and the men were kept under observation, but no departure from 
their normal state of health was observed (see also examination of 
bloods of contacts, p. 216). 

3. LalerU Infections. — ^These are cases in which infection has occurred^ 
but in some of which there is prolonged delay in the appearance of 
any illness, while in others there are only vague symptoms, insufficient 
to incapacitate the affected individual In such latent infections some 
lowering of vitality, the result of special stress or occurrence of other 
illness, may determine the onset. The following are illustrative 
cases: — 

(1.) Two of the hospital staff at Bighi were found by Staff-Surgeoik 
Whiteside to react to Micrococcus meliiensis, one as high as 1 in 300» 
without ever having been on the sick list, although in both cases there 
was a history of malaise during the previous summer, months before 
the examination. The man showing the reaction in lower dilutions 
subsequently developed an attack of Mediterranean Fever, the other 
did not. 

(2.) W. H. W., ordinary seaman, of the " Diana," was in Bighi 
Hospital from May 31 to July 12, 1905, with a fractured tibia. After 
July 27 he suffered from occasional headaches. His ship left Malta a. 
week after his discharge to her from hospital, and remained either at 
Candia or Suda Bay, with the exception of six days at Phalerum Bay,. 
until November 15, when she returned to Malta and stayed until 
December 18. During September, while engaged in stokers' training 
class, very trying work indeed, the patient had felt unwell, but did not 
go on the list or make any complaint. The ship left Malta again on 
December 18 for Port Said, where she remained until January 18, and 
then proceeded vid Suez and Port Sudan to Akaba in connection with 
the Turkish frontier dispute, arriving there on February 18 and 
remaining till May 22, a period of three months. Here she lay off & 
practically uninhabited coast, with which there was no communication,, 
and her only intercourse with the outside world was through a weekly 
steamer which brought provisions. On May 2, 72 days after arrival 
here, the patient was noted to be looking ill, and although he made no 
complaint he was placed on the list, and was found to have pyrexia 
and to give a good reaction with Micrococcus melitensiSj which was 
verified in the Commission laboratory on his arrival in Malta on 
June 1. He had not been ashore at all since general leave in Malta in 
December, 1905, and no cases had occurred in the ship since September,, 



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Ejpidemiologicdl Work in 1906. 



247 



1905. There were practically no mosquitoes at Akaba, and no 
inhabitants anywhere near. On the ship's return to Malta, all her 
Maltese, numbering 13, were examined, and one was found to react 
well, but his urine was plated out with negative result. The opinion 
of the medical officer of the ship was that the case was an ambulatory 
one, which had been contracted in Bighi in July, 1905, and idthough 
one cannot absolutely exclude the possibility of ship infection, this 
seems the most probable explanation in view of the history. 

Bruce states that cases have occurred in as short a period as six days 
after arrival in Malta. Johnstone quotes cases occurring eight and 
11 days after arrival In the course of the present enquiry the 
following additional cases have been noticed during our examination 
of army records : — 



• 


Age. 


Total 
service. 


Service in 
Malta. 


1. Private D., 8rd K.O. Yorkshire Light Infantiy ... 

2. Private J., lit Royal Qarrison Bedment 

8. Brammer D. 5th BoTal Munster ISisilidrs 


42 

40 
12 
19 
84 
86 
19 


years. 
18 
6/12 

1 

11/12 

8/12 

7/12 

1 


Iweek 

1 » 
16 days 

2 weeks 
2 ,. 

8 „ 
2 » 

11 days 


4. Private O., 2nd Loyal N. Lancashire Regiment ... 

5. Private P., 8rd Royal (Harrison Regiment 


0. Private T.. flrd Roval Garriflon Reiriment 


7. Gunner J., 68rd Company, Royal Garrison 

Artillery 

8. Private McG., Ist Royal Dublin Fusiliers 





Case 2 was admitted for Mediterranean Fever, but gave a negative 
reaction up to 24 days after admission. Case 5 was admitted for 
fever, but gave a negative reaction 13 days after admission and no 
positive reaction is recorded until over two months later. Case 7 gave 
a positive reaction 10 days after admission. The other cases gave early 
reactions. 

The longest interval between apparent exposure to infection and 
appearance of symptoms that came under Johnstone's observation, 
was the case recorded by Bassett-Smith, in which the interval was 
apparently two months. In the following case the possibilities of 
exposure to infection after the man had left Malta were practically nil, 
and the interval, as will be seen, was over three months. 

R. H., stoker, H.M.S. "Sentinel," was a patient in Bighi Hospital from 
January 20 to February 28, 1906, with syphilis. It was a mild case of 
syphilis, with chancre and secondary symptoms. No record of temperature. 
During his stay there he had no symptoms in any way suggestive of 
Mediterranean Fever, nor was there any previous fcfer history. He had 
three pints of milk daily for 26 days, and it was stated that he was quite 
weU on return to his ship. H.M.S. '* Sentinel *' left Malta on March 2. 
On the passage home, the ship arrived at Gibraltar on the 6th and remained 



Digitized by VjOOQ IC 



248 Major McCulloch, Major Weir, and Staflf-Surgeon Clayton. 

there till March 20, arriring at Plymouth on the 25th. This man did not go 
ashore either at Malta or CKhraltar. He had a fererish attack, starting on 
June 6, with pains in joints and swelling of knees and wrists, but he had 
recoTered bj June 16 and returned to duty. During the manoDuyres in 
June the ship called again at G-ibraltar, but onlj coaled, and sailed at onee, 
and was not again within the limits o Hbe Mediterranean station. This was 
on June 80, after the patient had had the feverish attack referred to. A 
recurrence of symptoms occurred on July 6, when he was sent to Plymouth 
Hospital, where he gare a positive agglutination reaction up to 1 in 500, 
and he died on July 18. 

The following cases, bearing on the same point, were kindly 
provided from the records of the home naval hospitals : 

Mr. G. F. returned from the China station, probably calling at Malta, and two 
months after return was attacked by illness, which, on admission to Plymouth 
Hospital in August, 1905, proved to be Mediterranean Fever. 

Commander W. F. B. left Malta at the end of March, and was placed on the sick 
list on Biay 11, but he first began to feel ill about the middle of April 

Mr. B. B. called at Malta from June 15 to 20, on his way home from China in 
the *' Andromeda.'* The onset of his attack, which was stated to be the first attack, 
and to be acute, wss on August 20. His blood reacted at Haslar up to 1 in 40. 

W. H. had returned from the Mediterranean six months previous to the onset of 
his attack on November 16, 1905, at Chatham. 

All these cases are reported to be first attacks. 

The following cases were obtained from military records : — 

The information from Egypt was kindly furnished by the Principal 
Medical Officer of that command. We are indebted to Lieut-Colonel 
J. B. Wilson, RA.M.C., for the particulars regarding the cases 
occurring in Alexandria, in 1905 and 1906, amongst men of regiments 
which had recently arrived from Malta. Lieut-Colonel Wilson had 
made special notes in these cases for the purpose of throwing light on 
the incubation period, and he considers it very improbable that the 
disease in any of the cases could have been contracted in Alexandria. 

It may be urged that the sequence of cases indicates the possibility 
of contact as a factor, and this possibility has already been mentioned 
(p. 148) in connection with the cases which occurred in 1905, at Cairo, 
amongst the men of the 1st Battalion King's Boyal Rifles, some 
months after the arrival of the i*egiment there from Malta. As in the 
Cairo cases, so in the Alexandria cases, the disease only appeared in 
men who had previously served in Malta. Against the contact view 
in the Alexandria cases it may be further stated, however, that the 
distribution was a scattered one, involving five companies out of eight, 
and the officers' mess, in the 18 cases belonging to the Dublin 
Fusiliers; and four companies and the officers' mess in the six cases 
belonging to the Worcestershire Eegiment 

It may be noted too that, as Cases 1 and 2 in the Dublin Fusiliers 
list were in hospital before the arrival of any of the other men 



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Epidemiological Work in 1906. 



249 



attacked in Alexandria, there is little possibility that they were the 
source of infection for the cases that occurred subsequently. 



Number. 



Date of 

arriyal in 

Alexandria. 



Date of 

onset of 

symptoms. 



Interval 

between 

leaTing 

Malta and 

onset. 



Bemarks. 



Ist Bojal Dublin 
Fusiliers — 



2 :":::::::::::: }^^/i^/K 

19/11/06 



3 

4 

6 

6 

7 

8 

9 

10 

11 

12 

18 

14 

15 

16 



17 
18 



4th Worcestershire 
.Regiment — 

19 

20 

21 

22 

23 

24 



11/ 5/06 



20/10/05 

23/10/05 

4/12/05 

10/12/05 

>5 
)6 
)5 
>5 
)5 
)6 
)6 
)6 
)6 
)6 



22/11/05 



14/ 5/06 
16/ 6/06 
17/ 6/06 
18/ 6/06 
21/ 5/06 
8/ 6/06 



dajs. 

14 

17 



27 
36 
38 
39 
46 
63 
64 
72 
77 
91 



7 

9 

10 

11 

14 



Admitted to sick list 
60 days after leaving 
Malta 

Admitted to hospital 
83 days after learing 
Malta 

First admitted for rheu- 
matic ferer, but this 
was probably an error. 
No blood examination 
was made until Feb- 
ruary 12, 1906, when 
he was again admitted 
and Mediterranean 
fever was diagnosed 



It will be further observed that there was a constant sequence of 
<;ases in the Dublin Fusiliers, up to 91 days after their departure from 
Malta. Then, notwithstanding the advent of the hot weather, the 
disease in this regiment entirely ceased 

Stronger still is the fact, that there followed an entire absence of 
Mediterranean Fever from the garrison of Alexandria until the arrival 



Digitized by VjOOQ IC 



250 Major McCulloch, Major Weir, and StaflT-Surgeon Clayton. 

of the Worcestersliire Eegiment from Malta, when the disease again 
made its appearance, but only among the men of that particular 
regiment. 

For the following cases we are indebted to Lieut.-Colonel Jennings^ 
Royal Army Medical Corps, Malta. 

A party of two ladies and a maid, travelling in the Mediterranean^ 
were on a steamer that went ashore at Malta on April 21, 1906, and 
they left Malta for England on May 7. One of the ladies devdoped 
Mediterranean Fever on May 9, and the attack proved one of great 
severity. In this case the incubation period may have been anything- 
up to 18 days. The second lady, who was companion to the first, was 
attacked eight days later, her illness dating from May 17, with an 
incubation period, therefore, of any time up to 26 days. The maid, 
on arrival in England, went to her home for a holiday on May 18, and 
she was attacked on June 6, or just about a month after leaving 
Malta. The doctor of the steamer, who was. in Malta during the same 
period, was also attacked, and the onset of his illness dates from 
May 25; and his attack was also one of great severity. The 
diagnosis in the first and foiuth of these cases was supported by 
positive agglutination reactions. 



ii. A Critical Examination of the Naval, Military and Civil. 

Observations. 

The important facts with regard to the ways in which the specific 
micrococci find their way out of the bodies of infected men, or of 
infected animals, may be summed up as follows. Examinations of the 
breath, saliva, sweat and scrapings from the skin have yielded negative 
results. The bowel discharges are still in the doubtful category. The 
micrococci have been recovered from the blood, and also from blood 
ingested by biting insects. The main paths, however, are in milk and 
in the urine, and of these the first is by far the more important. 

The possible paths of infection which have been advanced in 
discussions relating to the etiology of Mediterranean Fever include 
food stuffs, and particularly milk and its products, contact, mosquitoes, 
or other biting insects, infected dust, latrine and drain infection^ 
water, etc. 

Milk. — The main facts which have been established with regard to 
the infectivity of milk are : — 

1 . That a very large percentage of the goats in Malta are infected. 

2. That the milk of a large proportion of the infected goats has 
been found to contain the specific micro-organism, and often in 
enormous numbers. 

3. That the quantities present show great variations from time to 



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Hpidemiologieal Work in 1906. 251 

time, and no obvious relation has been observed to temperature or to- 
season of the year, either with regard to abnormal presence of 
Micrococcus meliiensis, or to their disappearance from an infected milk. 

4. That monkeys and other animals fed on naturally infected milk 
have contracted the disease as a result. 

5. That, in addition to the evidence relating to Malta, the disease* 
has been found to be associated with goats, both in India and the 
Orange Biver Colony ; and in India the specific organism has been^ 
recovered from the milk 

The evidence which we have collected with regard to the part 
played by the goat, and by milk obtained from it, may be divided into 
suggestive and direct evidence. 

(i.) Suggestive Evidence, — 1. Mediterranean Fever shows marked varia- 
tions in incidence in the various barracks, that is to. say, there is little 
or no evidence of persistent or constantly recurring place infection^ 
confined year after year to the same barracks or to the same parts, 
of barracks, but the same cannot be said of hospitals. 

2. Although, taken collectively, there is special prevalence of the 
disease in the hot weather months, it is found on examining the 
figures for the individual years of the series, 1899 to 1905, that 
considerable variations occur as to the months that show the highest 
prevalence. Seasonal prevalence would appear to be an argument 
against the milk hypothesis, but possible explanations may be, that if 
milk containing the micrococcus is left standing about, the conditions- 
are more favourable for multiplication of the organism in the hot than 
in the cold weather ; also that cream or milk with fruit, or in ice 
creams, etc., are more largely consumed in the hot months ; finally^ 
the debilitating influences of the hot season may reasonably be 
regarded as likely to increase individual susceptibility. 

The statements made in 1 and 2 apply also to the occurrence of 
cases amongst those resident, as patients or otherwise, in the Boyal 
Naval Hospital, Bighi. 

3. Every year there is very widespread distribution of cases of 
Mediterranean Fever in the garrison, no corps or barracks as a rule 
being exempt, but there are occasional outbursts of epidemicity which 
do not show any uniform preference for particular months of the year. 
For instance, the outbreak at Imtarfa in 1899 occurred from May to* 
July, while the epidemic at Floriana in 1903 was at its height from 
August to October. Table VI, p. 34, shows that in the naval hospital 
at Bighi the ratio of patients eventually developing the disease 
constantly differs in all four quarters of the year. 

4. In epidemic years the outbreak is usually confined to single units,, 
while nothing more than ordinary prevalence is observed amongst the 
rest of the garrison. It is important to remember, in this connection,, 
that milk is not a Government supply, and the milk for the different 



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252 Major McCulloch, Major Weir, and Staflf-Surgeon Clayton. 

units and officers' messes was obtained from very various sources, each 
unit and mess making its own arrangements. 

5. One of the most striking statistical facts is that, in proportion to 
strength, the liability of the military officer to attack is over three 
times as great as in the case of the man, and very much the same is 
noted in the navy also. It is also important to observe that soldiers' 
wives are attacked in the proportion of two to one as compared with 
the men. Officers and women are more in the way of consuming milk 
in various forms than the men. The civil statistics do not show the 
.same liability to attack on the part of the female, the relative numbers 
of notifications being about equal for the two sexes. 

6. The disappearance of Mediterranean and simple continued 
ievers from Gibraltar in the coiu*se of the last 20 years has been stated 
by Horrocks to be coincident with the cessation of importation of 
^oats from Malta and the probable exodus of infected goats from the 
Kock 

7. During 1906 there has been a remarkable diminution in the pre- 
valence of Mediterranean Fever in both fleet and garrison, and it is 
significant that, so far as the civil notifications can be relied upon, no 
corresponding reduction is observed, up to the end of September, as 
regards the civil population, which are the latest figures in our 
possession. In both services this has closely followed the preventive 
measures relating to milk detailed in other parts of this report. So far 
4is the Navy is concerned, the only alteration in preventive measures 
has been the increased attention paid to the control of the milk supply. 
The isolation of Mediterranean Fever cases has been carried out for 
some years past at Bighi. In the garrison, besides the general sub- 
stitution of condensed for goats' milk, isolation of Mediterranean Fever 
cases was simultaneously carried out. 

8. It is important to observe that isolation of cases was not in 
itself sufficient in previous years to prevent the frequent occurrence 
of Mediterranean Fever amongst patients in other parts of the hospital 
^t Bighi 

(ii.) Direct Evidence. — 1. The history of the s.s. "Joshua Nicholson," 
•detailed in another part of the Eeport, practically demonstrates the 
possibility of the infection of man by the ingestion of goats' milk. 

2. Enquiries into the milk histories of service patients this year 
have elicited the fact that, in the large majority of the cases, a direct 
relation with the use of fresh milk could be traced. The evidence 
obtained from investigations as to the relative prevalence of Mediter- 
ranean Fever amongst the consumers of condensed milk chiefly, and of 
fresh milk chiefly, have uniformly shown that the chances of infection 
^re much greater in the case of the latter. 

3. The examinations of goats made in connection with barracks 
and other establishments in which Mediterranean Fever was prevalent 



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Epidemiological Work in 1906. 255 

have invariably shown the presence of infected goats, and that the milk 
of some contained the Micrococcus melitensis. 

4. Dr. Critien's paper gives a number of cases in which Mediter- 
ranean Fever occurred in the civil population among consumers of 
goats' milk which was found on examination to contain the specific 
organism. A good piece of negative evidence is provided hy 
Dr. Caruana Scicluna's facts relating to the Institute of the Good 
Shepherd at Balzan, to the effect that when the milk supply is 
uniformly obtained from healthy goats, no cases of Mediterranean 
Fever occur. 

Contact. — Inoculation is a certain way of conveying the disease^ 
as witness the laboratory cases in which it has followed wounds with 
infected articles. It is, therefore, probable that the disease is some- 
times acquired through infected milk, or less often urine, coming in 
contact with breaches of the surface. Infection of goats and of goat- 
herds is likely to occur in this way. Contact with infected material 
was also the most probable explanation of the infection of the three 
RA.MC. laboratory attendants, one in 1905 and two in 1906. 

As far as the evidence obtained during the investigation of individual 
cases in barracks is concerned, although the possibility of contact 
cannot always be excluded, the balance of evidence goes to show that 
it is probably not a frequent factor. Very few of the men who have 
come under observation as " contacts " with cases of the disease have 
had to be subsequently admitted for it, and for the few there are other 
possible explanations. 

One or two instances have come under observation in which persons 
with no previous history of fever have occupied the same bed as a 
Mediterranean Fever patient, for weeks together, without contracting: 
the disease by so doing. 

The large prevalence of Mediterranean Fever among attendants on 
the sick would at first sight appear to indicate that contact was a 
factor of primary importance, but the cessation of cases amongst sick 
attendants, in both naval and military hospitals in Malta, since the 
milk change is rather suggestive that contact cannot be a very potent 
factor. Away from Malta, sick attendants on Mediterranean Fever 
cases do not contract the disease in the performance of their duties,, 
as, for example, on the hospital ship " Maine," and in Home military 
and naval hospitals. Nor are any instances known, in Home hospitals, 
of patients admitted for other ailments contracting the disease 
through being treated in the same ward with Mediterranean Fever 
cases. Evidence tending in the same direction is derived from a study 
of the occupations of the Sick Berth Staff attacked at Bighi. 

The possibility of Mediterranean Fever being contracted during 
sexual intercourse requires mention. The disease has often been 



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254 Major McCulloch, Major Weir, and Staff-Surgeon Clayton. 

observed to supervene in cases admitted for venereal disease. The 
Micrococcus Tnelitensis has been recovered from the urine of prostitutes 
and from vaginal swabbings. It is, however, probably not a frequent 
path of infection, and milk diet in hospital is likely to have been the 
-source of a considerable proportion of these cases in the past. 

Biting Insects. — The experimental evidence obtained in 1906 does 
not lend support to the view that the disease is commonly transmitted 
to man by the bite of infected mosquitoes. The monkeys experimented 
upon were each bitten by batches of mosquitoes, which in turn had 
l>een separately fed on grossly infected guinea-pigs. That the 
imosquitoes contained infected blood was determined by the recovery of 
the Micrococcus meUiensis from ingested blood and from mosquito 
•droppings. Yet, although the conditions were infinitely more favour- 
able for the conveyance of infection to the monkey than could ever 
possibly obtain for the infection of human beings by mosquitoes con- 
taining blood drawn from a human source, only one very doubtful 
instance of infection occurred among the 14 monkeys concerning 
which accurate data are available. This is in marked contrast 
to the almost universal success which attended the milk feeding 
•experiments. 

The epidemiological evidence also tells against the mosquito 
propagation theory, as will be ^seen from the following con- 
siderations : — 

1. The evidence obtained from the investigations of individual cases 
in 1906 is altogether negative. Answers to questions as to whether 
a man has or has not been bitten by mosquitoes are possibly of no 
great value, as many men pay little heed to mosquito bites. From 
patients who had contracted the disease during the earlier months of 
the year the answer was commonly in the negative, whereas aflir- 
mative replies were frequent in the warmer months. 

2. The disease continues to> prevail at seasons of the year when 
mosquitoes are few, or when they seem to be almost absent, as in the 
•earlier months of 1906. 

3. There was considerable prevalence of Mediterranean Fever in the 
garrison during the first six months of 1906, but a large reduction in 
prevalence occurred in July, August, and September, when mosquitoes 
were abundant. 

4. Cases have come under observation in which the most careful 
attention was paid to the use of mosquito nets, yet the disease was 
-contracted. 

5. The use of mosquito curtains in the Mediterranean Fever wards 
at Bighi for years did not prevent the occurrence of many cases in the 
'Other wards of that hospital. 

6. Officers, who as a class make free use of mosquito nets, are three 



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Epidemiological Work in 1906. 255 

times more liable to contract the disease than the men, who are not 
protected from mosquito bites at all. 

7. The Camerata married quarters are surrounded by a dense civil 
population, amongst whom there must be abundant opportunities for 
mosquitoes to become infected, yet the incidence of Mediterranean 
Fever is generally light. 

8. A study of the cases that have developed in the Royal Naval 
Hospital at Bighi, where isolation has been the rule for some years, 
«hows that propinquity to the potential sources of infection — 1.6., the 
Mediterranean Fever wards — has had little influence in determining the 
-contraction of the disease, notwithstanding the presence of abundance 
of mosquitoes. 

9. The evidence given in the naval part of this Report, in connection 
with docking, also argues against mosquito infection. 

Sand-flies were much more troublesome than mosquitoes in 1906 in 
49ome of the barrack blocks and married quarters. They have a very 
general distribution in Malta and they suck blood voraciously, their 
bite causing intense irritation, which leads to scratching, and, especially 
with children, to the formation of nasty-looking sores. If biting insects 
can convey the disease, the sand-fly has advantages over the mosquito, 
^is it bites more freely, and nets afford little or no protection. There 
is no evidence that the disease has been conveyed by it. The same is 
true of another blood-sucking fly, the Stomoxys ccUcilrcmSy although it is 
known to be able to act as the host of the Micrococcus melitensis for a 
few days. 

Bugs and fleas cannot be at present incriminated. 

FuES. — The possibility of flies being carriers of the specific micro- 
cocci must be remembered. In goat houses and goat pens flies are 
•often present in enormous numbers. They swarm in milking places 
which are sodden with goats' milk and urine. They are often 
■abundant in latrines, where they may come in contact with infected 
urine. Arguing from the analogy of enteric fever, the fly may alight 
on infected matter, and may carry the cocci on its body or legs to 
iood, etc. The fly as a carrier of the disease is discussed in connection 
with some cases in the West Kent Regiment. 

DuST.^The disease has been conveyed to healthy animals by 
•dust, artificially contaminated. The fact that Micrococcus melitensis is 
readily killed by exposure to sunlight, and the rapid dilution that 
must occur when the dust is blowing about under natural conditions, 
are against dust being a common factor in the spread of the disease. 
Localised gross contaminations are possible, as, for example, the 
surfaces of places in regular use for goat milking, which must neces- 
sarily become sodden with milk and urine, and here the possibilities 



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256 Major McCulloch, Major Weir, and StafiF-Siirgeon Clayton. 

will be in direct proportion greater. The possibility will be even 
greater in milking places and goat pens shaded from the sun. The 
evidence obtained in 1906 is against dust infection. 

Drain Emanations. — Hughes favoured the view that emanations 
from drains and sewers played a large part in the direct causation of 
this fever. Davies discussed this point at some length (Part IV of the 
Commission Seports), and we can only add that we have been unable to 
gather any evidence supporting Hughes' views during our investigation 
of the cases occurring amongst the troops in 1906. 

Foods. — No evidence against foods other than milk has as yet been 
obtained. It has been found that the Miciococcus meliiensis retains its 
virulence in loeally-m^e cheese. Local butter and local cheese are 
not used by the troops. We have only come across two instances in 
which local (Cozo) cheese had been eaten. 

Water. — Miei-ococcus melitensis has never been found in water under 
natural conditions. The scattered distribution of the cases of 
Mediterranean Fever in barracks, which is the rule, is against water- 
borne infection. 

iii. Recommendations. 

As the goat is more than probably the primary source of the 
disease in the vast majority of cases, if not in all cases, and as goats' 
milk is the common vehicle for the Micrococcus meliiensis, it follows 
that preventive measures, to be effective, must be based on sound 
regulations, framed with a view to stamping out the disease in the 
goats. In the meanwhile, there should be a vigorous control both of 
the goat traffic and of milk supplies. 

It will not be an easy matter, perhaps, to alter customs which 
have been in use for many generations, and it may prove impossible 
to do so otherwise than gradually. There will be much prejudice to be 
overcome, and even much active opposition on the part of some 
sections of the public, especially those who make their living by 
keeping goats and vending milk, and also on the pai-t of many 
consumers, as it is a common argument in Malta that a large section 
of the people prefer to have the goats brought to their doors and 
there milked. Public opinion will have to be educated in the matter, 
and it will probably be necessary to combine the suaviier in modo with 
the fortiter in re. 

The local authorities, both civil and belonging to the two services, 
are fully aware of the facts that goats are sources of the disease, 
and that infection of milk is both widespread and common. 

The Civil measures which are in operation are as follows : — 

1. Notification, — All cases of fever lasting more than seven days 



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Epidemiological Work in 1906. 257 

are to be notified. We have good reasons for believing that many 
cases of Mediterranean Fever either do not come under observation at 
all, or that the medical practitioners fail to notify. This requires 
improvement, and, perhaps, the payment of a small fee. 

2. Blood ExarmnaUons. — The Public Health Department undertake 
the examination of samples of blood from civil cases, but although 
facilities have been offered to civil practitioners during the last two 
years, they have only been made use of in less than a quarter of the 
cases notified as suffering from Mediterranean Fever. There is also 
room for further improvement here. 

3. Sanitary Inspection, — A sanitary inspector visits each case notified 
and makes special inquiries into, amongst other things, the kind 
of milk used and its sources, occupation, the sanitary conditions of 
the premises, contact with previous cases, etc. Inspections of the 
sanitary conditions of goat houses, etc., also come within the scope 
of their duties. Some special work is being done by the medical 
officers of health, as will be observed from Dr. Critien*s paper. 

4. Segregation of Goats. — It is in contemplation to make arrange- 
ments for the segregation of reacting goats as a general practice, 
and to kill off those that are found to be persistently infected, and in 
both cases the question of compensating the owners is in point. 

The Service measures in operation are : — 

1. Notification. — This may be regarded as complete. 

2. Milk — Condensed milk has been substituted for goats' milk 
in both military and naval hospitals. This change had been decided 
on just before the goat-herds' strike in May in the case of the military 
hospitals, and it dates from the period of that strike in the case of 
barracks. We had begun the campaign against the use of goats' milk 
in barracks and hospitals at the end of 'April. 

3. Goats, — The entry of goats into barracks has been prohibited, as 
well as their being kept in the neighbourhood of barracks. 

4. Instructions to Soldiers and Married Families, — Soldiers and the 
married soldiers' families have been warned as to the dangers of using 
goats' milk, and they are being taught that it is very necessary to 
guard against making use of goats' milk, or of articles made from it, 
outside their barracks or quarters. 

Measures for stamping out the disease resolve themselves into 
measures for dealing with infected goats, and measures directed to 
control of the milk supplies. Measures of this kind have already 
been dealt with in the Reports to the Commission by Horrocks and 
Kennedy {vide Part IV, p. 82). 

These observers recommended : — 

1. That the perambulation of goats through the streets of the 
towns in Malta should be strictly forbidden. 

2. That all goats showing a persistent blood reaction should be 
(2089) s 



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268 Major McCuUoch, Major Weir, and Stafif-Surgeon Clayton. 

destroyed, as examinations of milk alone cannot be taken as a basis 
of action, owing to the excretion of the Micrococcus melUensis being 
intermittent in character. 

3. That the milking of goats should be done in their pens or in 
some central dep6t. 

4. That the goats should be penned as far as possible from human 
habitations. 

5. That the milk should be transmitted to the towns in sealed cans. 

6. That promiscuous micturition should be prohibited, and a 
penalty imposed on offenders. 

The second of these measures implies, of course, the organisation 
of arrangements for the examination of goats and for the segregation 
of those found to be infected for further observation. It would be, 
perhaps, beyond the limits of practicability to undertake the 
systematic observation of all the goats in Malta. It would mean 
making from 15,000 to 20,000 milk or serum agglutination tests every 
few weeks. The practical measure, at all events to begin with, would 
appear to be the examination of all goats suspected to be infected, 
and occasional test examinations of herds. 

We recommend, in addition, that all goats intended for exportation 
should be examined before shipment, say a fortnight before and again 
a day or two before being shipped, and no reacting goat should be 
allowed to be put on board. 

We do not agree that goats should be milked in their pens, but we 
strongly support the formation of milk depdts in all important centres, 
which, if not Government institutions, should be under the control 
and strict supervision of the Public Health Department. We are in 
complete agreement with the rest of the foregoing recommendations. 

The existing sanitary laws would appear to give sufficient powers to 
the authorities, both in regard to the control of the goats and of the 
sale of milk to the public, if they are only enforced and carried out 
both in spirit and in letter. 

The Malta Sanitary Ordinance, No. Ill of 1904, Chapter 11, 
Section V, Articles 79 to 100, already provides : — 

1. That all purveyors of milk shall be licensed, and that the licence 
shall only be granted on condition that the dairy is well built, fitted 
with impervious floors, well ventilated, and otherwise sanitary 
(Articles 79 and 80). 

2. Dairies are to be kept clean and periodically limewashed 
(Article 81). 

3. Goats and cows are to be notified and inspected (Articles 82 
and 83); and cows are to be branded on the horns and hoofs 
(Article 82). 

4. Sickness is to be at once notified and the animal inspected. If 
the disease from which the animal is suffering be declared infectious. 



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Epidemiological Work in 1906. 259 

the person authorised to inspect the animal shall forbid the sale of the 
milk, and shall apply other preventive measures (Article 84). 

5. No milking operations or any handling of milk shall be made by 
anyone who may be suffering from, or recently convalescent from, any 
infectious disease, or who lives in the same house with such cases 
(Article 86). Certain diseases are specified, but Mediterranean Fever 
is not named among them. 

6. Living places are not to be used for storing milk, and cow sheds 
shall not communicate with the place in which milk is kept or sold, 
but shall be separated therefrom by an open space (Articles 87 
and 88). 

7. The cleanliness and method of cleansing of utensils and vessels 
used for the preservation and sale of milk is also legislated for 
(Articles 89 and 90). 

8. No one shall expose or keep for sale the milk of animals stricken 
with any disease held to be capable of altering the natui'e of the milk 
(Article 91, 6). 

9. It is part of the duty of the Government veterinary surgeon to 
watch over the hygiene of stalls, and the state of health of animals 
destined for the production of milk. (Ordinance dealing with the 
organisation of the Public Health Department, Chapter VIII, 
Article 40, e.) 

10. There is a Council of Health which advises the Government on 
all matters affecting hygiene and the public health. It has on it one 
naval and two military representatives. 

The relative importance of goats and cows, as sources of milk 
supply in Malta, did not receive due consideration when this 
Ordinance was framed, as in many of the provisions the word " cow " 
alone is used, and it is only by implication that they can be held to 
apply to goats. 

Actual observations of the conditions obtaining in the places where 
goats are penned or housed, which were made in the course of our 
work, show that the regulations in regard to housing are more 
honoured in the breach than in the observance. The Ordinance is yet 
young, and it has to be remembered that the enforcement of the law 
means very radical alterations in the conditions previously prevailing. 
It was an attempt to enforce the provision of impervious flooring and 
limewashing in specific instances that led to the goat-herds' strike. The 
goat-herds are an uneducated class, and much prejudiced against what 
they consider unnecessary innovations. It will probably take a long 
time before these prejudices are overcome, and the only alternative 
appears to be dairies or depots belonging to Government, or large 
owners, and in the latter case mider Government control. 

To sum up, we recommend as follows : — 

(2089) s 2 

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260 Major McCulloch, Major Weir, and Stafi'-Surgeon Clayton. 

A. Measures relating to Goats. 

1. The perambulation of goats through the streets should be strictly 
forbidden. 

2. The branding of goats on the hoofs should be carried out, as in 
the case of cows. 

3. The goats should be penned or housed as far as possible from 
human habitations. 

4. Examination of goats suspected to be infected. 

5. Examination of all goats intended for exportation before ship- 
ment. 

6. Segregation of reacting goats for observation. 

7. Destruction of goats showing persistent infection. 

8. Compensation to owners on two scales : (a) while their goats are 
segregated, and (b) for goats destroyed. 

B. Measures relating to MUk Supplies, 

1. The establishment of large dairies or depdts under Government 
control or supervision. 

2. The transmission of the milk in sealed cans to proper dairies in 
the towns. 

C. Other Measures relating to tJie Civil Population. 

1. More strict notification. 

2. Efforts should be made to extend the practice of having blood 
examinations made in cases of fever. 

3. Impress on sanitary inspectors the importance of their milk 
enquiries. 

4. As recommended by Horrocks and Kennedy, educate the people 
by leaflets telling of the importance of preserving some degree of 
sanitation in their dwellings, the dangers of infected milk, need for 
milk sterilisation, etc. 

5. Promiscuous micturition in the streets and roads should be pro- 
hibited, and a penalty imposed on offenders. 

6. Latrine accommodation should be provided for workmen 
employed in building operations. 

D. Measwres specially applicable to the Services, 

1. With regard to the garrison, the isolation of Mediterranean 
Fever cases should be continued. 

2. The entry of goats into barracks or other Government places 
should be strictly prohibited ; and they should not be allowed to be 
housed, nor should resting-places be permitted to be established in the 
neighbourhood of such places. 



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Epidemiological Work in 1906. 261 

3. Pending the possibility of obtaining ahsolvMy safe milk, the use 
of goats' milk, or its products, should be absolutely forbidden in any 
hospital, barracks, ship, or other Government establishment. Sterilisa- 
tion cannot be trusted. 

4. The use of condensed or other forms of preserved milk should be 
continued in hospitals and barracks, including messes and other regi- 
mental institutes. 

5. Continue the warnings to soldiers and to soldiers' families as to 
making use of goats' or cows' milk outside barracks or quarters. 



Habbisoit avd Sons, Printers in Ordinaiy to Hu Majestj, St. Martin's Lane. 

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EOYAL SOCIETY. 



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COMMISSION FOR THE INVESTIGATION 
OF MEDITERRANEAN FEVER. 

Part I. 

Price 3s. Pp. 111. 
Containing Baports by 

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and E. A. Shaw, R.N., and Dr. T. Zammit. 



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Price 2s. Pp. 80. 

Containing Reports by 

Dr. Ralph W. Johnstone, Fleet-Surgeon P. W. Bassett-Smith, R.N., 
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KEPORTS OF THE 

COMMISSION FOR THE INVESTIGATION 
OF MEDITERRANEAN FEVER 

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Price Zs, M. Pp. 187. 
Containing Beports by 
Stoflf-Surgeon E. T. Gilmour, RN., Staff-Surgeon E. A. Shaw, RN,, 
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RA.M.C., Dr. T. Zammtt, Fleet-Surgeon P. W. Bassett-Smith, 
RN., and Lt-CJol. A. M. Davies, RA.M.C. 



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